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APPLIED  ANATOMY  OF 
THE  LYMPHATICS' 


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BY 


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F<T.  MILLARD,  D.  O. 

TORONTO 

Author  of  Poliomyelitis;  Founder  and  President  of  The  National 
League  for  the  Prevention  of  Spinal  Curvature;  Founder  and 
President  of  the  International  Lymphatic  Society,  and  Editor 
OF  A  Quarterly  Journal  published  by  the  Lymphatic  Research 
Society;  Anatomical  Artist;  Originator  of  Water-marked  Spine 
in   Stationery  for  the  Osteopathic  Profession,  Etc.,  Etc. 


EDITED  BY 

A.  G.  WALMSLEY,  D.O. 

Collaborator  with  Dr.  Millard  in  Producing  Poliomyelitis;  Editor 
OF  Applied  Anatomy  of  the  Spine  by  H.  V.  Hat^laday;  Secretary 
OF  The  National  League  for  the  Prevention  of  Spinal  Curvature; 
Associate  Editor  of  the  Osteopathic  Magazine  and  the  Spinal 
League  Journal. 


Published  under  the  Auspices  of  the 

International  Lj^mphatic  Research  Society 

and  Copyrighted  by  this  Society,  1922 


THE  JOURNAL  PRINTING  COMPANY 

KiRKSviLLE,  Missouri 


)  lax 


LIST  OF  CONTRIBUTORS 

R.  M.  Ashley,  D.  O. 
John  H.  Bailey,  D,  O. 
Evelyn  R.  Bush,  D.  O. 

H.  L.  Collins,  D.  O. 

J.  Deason,  M.  S.,  D.  O. 

Edwin  Martin  Downing,  D  O, 

James  D.  Edwards,  D.  O.,  M.  D. 

George  M.  Laughlin,  M.  S.,  D.  O. 

Glenn  S.  Moore,  D.  O. 

C.  C.  Reid,  D.  O.,  M.  D. 

C.  Paul  Snyder,  D.  O. 


« 


Thoracic  Duct 


Affectionately  Dedicated 

To  My  Friend 
Carl  P.  McConnell,  D.  O. 


CONTENTS 

Preface 9 

Introduction 11 

Editor's  Preface 15 

CHAPTER  ONE 
The  Lymphatic  System:    A  General  Outline  of  Its  Applied  Anatomy. 

A  New  Method  of  Diagnosing  Various  Diseases  by  Palpating  Lymphatic  Glands. 
A  Lymphatic  Examination.    Venous  Stasis  and  Lymph  Blockage. 

CHAPTER  TWO 
Applied  Anatomy  of  the  Lymphatics  op  the  Head  and  Neck. 

Lymphatics  of  the  Tongue.     Lymphatics  of  the  ThjToid  Region.     Lymphatics  of 
the  Larynx  and  Trachea.     Lymphatics  of  the  Tonsils.     Lymphatics  of  the 
Teeth  and  Gums.     Pyorrhea,  Lymphatically  Considered. 

CHAPTER  THREE 

Applied  Anatomy  of  the  Lymphatics  op  the  Head  and  Neck  in  Relation  to 

Acute  Poliomyelitis. 

CHAPTER  FOUR 
Lymphatics  of  the  Thorax. 

Lymphatics  of  the  Lungs  and  Pleura.  Lymphatics  of  the  Axillary  Region.  Lym- 
phatics of  the  Heart  and  Pericardium.     Lymphatics  of  the  Esophagus. 

CHAPTER  FIVE 
Lymphatics  of  the  Abdominal  and  Pel\'ic  Regions. 

Lymphatics  of  the  Diaphragm.  Lymphatics  of  the  Liver.  Lymphatics  of  the 
Stomach  and  Intestines.  Lymphatics  of  the  Kidneys.  Lymphatics  of  the 
Pelvic  Region. 

CHAPTER  SIX 

Vaccines  and  Serums. 

Vaccines  and  Serums  in  Relation  to  the  LjTnphatic  System.  Vaccination  and  the 
LjTnphatics. 

CHAPTER  SEVEN 

The  Origin  and  Functions  of  the  Lymphatic  System. 

Edwin  Martin  Downing,  D.  O. 

Importance  of  the  Lymphatics.  The  Volume  of  L>Tnph.  Development  of  Lym- 
phatics. Anatomy  of  Lymphatic  System.  I^ymphatics  of  the  Intestines.  The 
Nerve  Supply.  The  Movement  of  the  Lymph.  Functions  of  the  Nodes.  Lymph 
and  the  Endocrines.  Transubstantiation  in  the  Lymph-Stream.  The  Lymph 
and  Nutrition.  The  Commissary  Department.  The  Lymph  in  Orthopedic 
Surgery.     To  Stimulate  Lj^mph  Flow.     To  Increase  the  Volume  of  Lymph. 

—5— 


6  Lymphatics 

CHAPTER  EIGHT 
Blood  Chemistry 
R.  M.  Ashley,  D.  O. 
The  Importance  of  a  Blood  Examination.     Blood  Analysis  to  Differentiate  the  Dif- 
ferent Forms  of  Diabetes.     Inter-Relationship  of  the  Spleen  and  Stomach.    The 
Spleen    and    Digestion.     Hodgkin's    Disease.     Acidosis.     The    Prevention    of 
Acidosis.     Cardiac  Dyspnea.     Non-Protein  Nitrogen  in  Blood  (NPN). 

CHAPTER  NINE 
The  Effects  of  Exercise  on  the  Lymphatics. 
Evelyn  R.  Bush,  D.  O. 
Exercise  Necessary  to  Maintain  Normal  Circulation.     The  Heart  Gains  by  Exer- 
cise.    Exercise  Makes  for  Efficiency.     The  Flexibility  of  Youth  May  be  Retained 
by  Proper  Exercise.     Activity  is  Life.     Most  Diseases  are  Benefited  by  Exer- 
cise.    Exercise  Promotes  Normal  Ljinphatic  Circulation. 

CHAPTER  TEN 
Part  One — Lymphatic  Glands  of  the  Neck. 
H.  L.  Collins,  D.  O. 
Groupings  of  Lymphatic  Glandular  Enlargements  of  the  Neck:     Group  One — Non- 
Tubercular  Cervical  Adenitis.     Group  Two — ^Tubercular  Cervical  Adenitis  or 
Scrofulous  Neck  Swellings.     Group  Three — Lymphatic  Enlargements  as  a  Re- 
sult of  Old  Syphilitic  Infection.     Group  Four — Hodgkin's  Disease  or  Pseudo- 
leukemia.    Group  Five — Cystic  Lymphangioma. 

Part  Two — The  Lymphatics  of  the  Chest. 
C.  Paul  Snyder,  D.  O. 
The  Workings  of  the  Lymphatics  of  the  Chest.     Interesting  Drainage  of  Lymphat- 
ics of  Pleura.     Poirier's  Explanation  of  the  Frequency  of  Pleurisy.     Treatment 
for  Drainage  and  Circulation  of  the  Thorax.     To  Promote  Vasodilatation. 

CHAPTER  ELEVEN 
Part  One — Lymphatics  of  the  Eye,  Ear,  Nose  and  Throat. 
C.  C.  Reid,  D.  O. 
A  General  Description  of  Lymphatic  System.     Seven  Large  Lymphatic  Stems.  Lym- 
phatic Notlcs  of  the  Head  and  Neck. 

Part  Two — Lymphatics  of  the  Eye  and  Ear. 
Glenn  S.  Moore,  D.  O. 
The  Importance  of  Lymph  Drainage.     The  Eye.     Gkucoma.     Triple  Lymphatic 
Drainage  of  the  Eye.     The  Ear.     Summary. 

CHAPTER  TWELVE 

Lymphatic  Drainage  of  the  Head  and  Neck. 

J.  Deason,  M.  S.,  D.  O. 

Physiologic  Properties  of  Lymph.     General  Anatomy.     Groups  of  Deep  Cer\'ical 

Glands.     Postpharj-ngeal  Lj-mph  Glands.     Anterior  Pharyngeal  Lymph  Glands. 

Tonsils  and  Lymph  Drainage.     Tubercular  Tonsillitis. 


Contents  7 

CHAPTER  THIRTEEN 
Finger  Surgery  in  the  Treatment  of  the  Lymphatics  of  the  Eye,  Eak,  Nose 

AND  Throat. 
James  D.  Edwards,  D.  6.,  M.  D. 
Lymph  Drainage  of  the  EyeHds.  The  Ocular  Ljinphatics.  Lymphatics  of  the  Aur- 
icle and  External  Auditory  Canal.  Finger  Surgery  of  the  Auditory  Lymphatics. 
The  Eustachian  Lymphatics.  Finger  Surgery  of  the  Eustachian  Lymphatics. 
Lyrr  phatics  of  the  Nasal  Cavity.  Finger  Surgery  of  the  Nasal  Lymphatics. 
Lymph  Drainage  of  the  Oral  Cavity.  Finger  Surgery  of  the  Oral  liymphaties. 
The  LjTnph  Drainage  of  the  Larj'nx. 

CHAPTER  FOURTEEN 

A  Consideration  of  the  Lymphatics  of  the  Eye,  Ear,  Nose  and  Throat  in 

Health  and  Disease 
John  H.  Bailey,  D.  O. 

Lymphatics  of  the  Nose.  Tuberculosis  Prevented  by  a  Healthy  Nose.  Suppurative 
Rhinitis  a  Serious  Svmptom.  Wonderful  Mechanism  of  Drainage  in  Normal 
Sinuses.  A  Normal  Pharynx  is  to  the  Child  What  a  Normal  Nose  is  to  the  Adult. 
Drainage  of  the  Pharynx,  Nose  and  Ear.  Osteopathy  for  School  Children. 
Normal  and  Abnormal  Adenoid  Tissue.  Normal  Tonsils  Closely  Related  to 
Immunity.  When  to  Suspect  "Adenoids."  Symptoms  of  Adenoids.  Opera- 
tion for  Removal  of  Adenoids.  The  Lingual  Tonsils.  The  Faucial  Tonsils. 
The  Tonsil  has  a  Wide  Range  of  Motion  and  is  Not  Firmly  Bound  Down  to  the 
Sinus  Tonsillaris.  Tonsillectomy  May  be  Avoided  by  Freeing  the  Phca  and 
Training  the  Crypts.  Relation  of  Tonsils  to  Deafness.  Every  Inflamed  Ton- 
sil Should  be  Accurately  Diagnosed  and  Adequately  Treated.  When  to  Advise 
Operation.  Improving  the  Drainage  trom  the  Tonsil.  Tonsillar  and  Periton- 
sillar Abscess.  Treatment  of  Pyorrhea.  Edema  of  the  Larynx.  Mucous 
Membrane  of  the  Tympanum  or  Middle  Ear.  Acute  Otitis  Media.  The  Nose 
and  the  Sinuse3  in  Eye  Conditions.  Manipulations  of  the  Eyeball  and  Adjacent 
Structures. 

CHAPTER  FIFTEEN 

The  Relation  of  the  Lymphatics  to  Infections  and  to  Malignancy. 

Geo.  M.  LaughHn,  M.  S.,  D.  O. 

The  Lymph  Glands  a  Defensive  Mechanism.  Case  Report  No.  1 — Infection  of  Right 
Elbow  Due  to  Infected  Tonsils.  Case  Report  No.  2 — Persistent  Swelling  of 
Neck  Glands  Requiring  Surgical  Treatment.  Do  Not  Manipulate  Enlarged 
LjTnph  Glands.  Case  Report  No.  3 — Injury  of  Leg  Which  Later  Became  In- 
fected Through  the  Blood  Stream.  Inguinal  Lj-mphatic  Involved.  Case  Re- 
port No.  4 — Deep  External  Iliac  L\TTiph  Glands  so  Enlarged  as  to  be  Mistaken 
for  Fibroid  Tumor  of  I'terus.  Cured  by  Incision  and  Drainage.  Case  Report 
No.  c — Sarcoma  of  Hip.  Secondary  Involvement  of  Adjacent  Lj'mph  Glands. 
Case  Report  No.  6 — Removal  of  Breast  Due  to  Broken  Down  Cyst.  Ljinph 
Glands  Infected  Secondarily.  Interesting  Case  of  Carcinoma  of  Breast  in  Wom- 
an Sixty  Years  of  Age.  Case  Report  No.  7 — Inoperable  Case  of  Carcinoma  of 
Stomach.  Adjacent  Lymph  Glands  Enlarged.  Case  Report  No.  8 — Carci- 
nomatous Obstruction  of  Bowel.     Mesenteric  Lj-mph  Nodes  Enlarged. 


The  Author 
F.  P.  MII.l.AHD,  D.  O. 


PREFACE 

Realizing  that  we  are  writing  upon  a  subject  that  in  some  respects 
is  new  to  the  world,  we  enter  upon  the  discussion  of  the  lymphatic  sys- 
tem in  a  spirit  of  respect  for  the  field  of  thought  that  lefiects  research 
activity.  As  far  as  we  know,  this  is  the  first  comprehensive  attempt 
that  has  been  made  to  outline  a  method  of  diagnosis  by  palpation  of 
the  lymph  nodes  of  the  body.  We  desire  in  this  treatise  to  emphasize, 
first,  the  applied  anatomy  of  the  lymphatics,  second  to  demonstrate 
the  possibility  of  determining  the  stage  diseased  organs  and  tissues  are 
in  through  a  method  of  palpation  of  lymph  nodules  at  strategic  points, 
and  third  to  outline  a  method  of  clearing  the  system  of  toxic  products 
through  specific  work  on  nerve  centres  that  directly  and  indirectly  reach 
the  lyluphatic  nodules  and  vessels.  The  text  books  on  anatomy  so  far 
have  given  but  meagre  information  on  this  great  system,  and  physiolo- 
gists give  us  little  to  go  by  in  touching  upon  the  function  of  this  sub- 
sidiary system  of  circulation,  that  is,  in  reality,  of  more  significance  in 
some  respects  than  that  of  the  vascular  system  conveying  the  great 
blood  stream. 

We  have  been  fortunate  in  securing  a  number  of  specialists  to  assist 
in  giving  their  experiences  in  dealing  with  this  system,  as  applied  to 
specialized  areas.  They  have  noted  certain  findings  in  their  research 
work,  and  have  collected  data,  and  have  written  for  this  book  such  facts 
as  they  can  corroborate  in  their  daily  clinic  work  as  specialists. 

It  is  hoped  that  this  little  book  will  be  welcomed  by  those  who  are 
students  of  the  human  body,  as  all  physicians  should  be,  and  that  within 
a  few  years  at  the  most  we  can  add  much  to  our  findings,  and  record 
them  in  a  new  edition,  that  will  be  much  larger  and  more  .complete. 

In  making  the  original  drawings  to  illustrate  the  text,  the  author 
has  had  no  precedent,  in  many  instances,  and  has  had  to  rely  upon  dis- 
sections and  in  some  instances  autopsies.  In  time  we  may  find  that 
we  have  only  touched  this  great  subject,  but  we  will  present  as  best  we 
can  our  findings  thus  far,  and  only  hope  that  at  some  future  date  we 
may  understand  more  fully  a  system  that  deals  so  directly  with  diseased 
conditions,  and  is  so  closely  allied  with  all  pathological  phases. 

We  will  try  and  not  cover  the  ground  that  anatomists  so  far  have 
outlined,  but  will  deal  as  directly  as  possible  with  the  more  important 
phase  namely,  the  applied  anatomy  of  the  lymphatic  system. 

We  wish  to  express  our  indebtedness  to  Drs.  Bush,  Edwards,  Forbes, 
Deason,   Collins,   Reid,    Muttart,   Snyder,    Ruddy,   Moore,  Downing, 

—9— 


10  Lymphatics 

Ashley,  Laughlin  and  Bailey  for  their  assistance  in  making  this  book 
instructive  and  original;  and  to  Dr.  A.  G.  Walmsley  for  editing  the  book. 
To  Miss  Logier  we  wish  to  add  our  appreciation  for  assisting  in 
making  water  washes  of  the  original  drawings  I  have  made  in  order 
that  half  tones  might  be  used  to  clarify  the  text, 

F.  P.  Millard,  D.  O. 
Toronto. 
Oct.  8th,  1921. 


INTRODUCTION 

Outside  of  surgical  references,  very  little  has  been  written  on  this 
subject.  The  references  found  pertain  to  nodes  being  involved  in  can- 
cerous conditions,  and  the  spreading  of  the  disease  to  adjacent  nodes 
and  channels,  but  we  have  to  deal  in  ordinary  practice  with  nodular 
involvement  relative  to  disorders  not  necessarily  of  a  malignant,  spe- 
cific or  tubercular  nature.  The  majority  of  disturbances  and  organic 
involvements,  from  colds  to  fevers,  have  a  bearing  upon  the  lymphatic 
system,  as  it  is  quite  impossible  to  consider  any  organic  disturbance 
that  does  not  include  a  lymphatic  change. 

Viewing  the  lymphatic  system  in  its  entirety,  as  a  complete  system 
within  itself,  we  may  be  surprised  when  we  recall  its  important  relation- 
ship to  almost  every  tissue  and  organ.  Just  for  a  moment  separate,  in 
your  mind,  this  system  from  the  vascular  and  see  how  complete  it  is. 
The  part  the  lymphatic  system  plays  in  its  close  relationship  to  the  tissues 
in  nourishment,  assimilation,  secretion,  and  elimination  or  purification, 
the  part  this  system  plays  'n  infected  areas,  and  the  immediate  activi- 
ties of  the  nodes  and  channels  whether  a  finger  is  cut  or  a  heel  bruised, 
the  long  tinted  lines  on  the  arm  when  blood  poison  has  started  through 
an  infected  abrasion'  of  finger  or  hand,  thocheckirg  up  and  collecting  of 
septic  materials  that  help  to  prevent  sudden  poisoning,  and  greatest  of 
all  the  necessity  of  perfect  vascular  normality  to  assist  the  lymphatics 
functioning  better  under  stress. 

The  vasomotor  arrangement  in  relation  to  the  nodes  and  large 
ducts,  and  the  nerve  centres  from  which  impulses  come  are  included  in 
this  picture  of  the  complexity  of  this  wonderful  system. 

We  can  but  touch  the  bare  outline  in  a  book  of  this  size,  but  we  hope 
within  a  few  years  to  have  worked  out  a  more  or  less  complete  applied 
analysis  of  the  disturbances  and  relations  of  the  lymphatic  system  to  the 
muscles,  ligaments  and  organs  that  are  closely  associated  with  them. 
In  the  head  and  neck  alone  there  are  numerous  disturbances  that  reveal 
lymphatic  disorders,  when  we  pause  to  think  of  the  relations  of  the  lym- 
phatic nodes  and  channels  that  become  involved  through  lesions  of  an 
osseous  nature.  There  are  few  areas  that  have  no  lymphatics,  very 
few.  The  lymphatic  system  completely  separated  from  the  body  would 
be  an  amazing  spectacle. 

Sensitive  to  a  degree,  and  carrying  diseased  nodular  infection  oft  times 
without  enlargement  of  palpable  significance,  this  system  is  more  or 
less  constantly  charged  with  infectious  material  or  septic  poisoning. 

—11— 


12  Lymphatics 

The  function,  in  part,  of  this  system  is  to  purify  or  clarify  the  contents 
of  its  nodules,  channels  and  ducts. 

The  enlarged  nodes  are  often  at  a  distance  from  the  point  of  infected 
abrasion  or  tissue  poisoning. 

Obstruction  of  the  vasculai*  system  is  but  an  occasion  for  lymphatic 
inactivity  and  nodular  trapping. 

The  unstable  vasomotors  through  lesions,  congestion  or  thickened 
tissues,  throw  upon  the  lymphatics  great  responsibilities. 

Organic  irregularities  cause  this  system  to  become  more  or  less 
blocked  and  taxed  from  the  points  of  infection  to  the  termination  of 
the  ducts. 

The  regurgitations  often  referred  to  in  gastric  and  other  organic 
centres  spell  systemic  symptoms  and  tissue  derangements. 

In  previous  articles  in  the  A.  O.  A.  Journal  we  have  pointed  out  the 
value  of  associating  enlarged  nodes,  through  palpation,  with  adjacent 
or  even  distant  sources  of  tissue  or  organic  infection.  The  blisters  on 
the  heels,  or  soft  corns,  and  inter- phalangeal  abrasions  that  invariably 
cause  popliteal  lymphatic  enlargement,  usually  with  tenderness,  are 
examples.  Sometimes  even  the  inguinal  glands  are  noticeably  involved, 
as  careful  palpation  reveals. 

We  used  to  consider  femoral  and  inguinal  nodular  enlargements 
due  to  pelvic  congestion  or  venereal  troubles,  but  when  we  remember 
that  this  region  is  the  drainage  point  for  all  points  below,  we  have  to 
admit  the  possibility  of  pedal  infection  involving  these  nodes. 

Likewise,  in  hand  or  finger  abrasions  with  infection,  we  may  notice 
a  glandular  involvement  of  the  axillary  nodes,  and  inr  some  instances 
the  cervical.  This  may  arouse  suspicion  regarding  the  mammary  region, 
but  not  necessarily,  although  a  secondary  disturbance  may  involve  the 
pectoral  region.  When  the  axillary  nodes  are  readily  palpable  it  will 
be  well  to  examine  each  finger  and  thmnb  around  the  nail  and  its  matrix, 
also  between  the  fingers,  to  see  if  anything  from  a  cuticle  abrasion  to  in- 
terdigital  cracks  are  present  in  the  skin. 

Anj'  source  of  infection  should  be  handled  immediately  to  prevent 
strain  upon  the  lymphatic  system  that  is  usually  already  burdened  in 
the  ordinary  system. 

Few  people  are  in  such  good  health  that  they  have  normal  lymphatic 
channels  and  lymphatic  fluid.  Every  abrasion  of  the  skin,  every 
abscessed  tooth,  every  diseased  tonsil,  sluggish  organ  and  congested 
area  means  a  more  or  less  irritated  and  overburdened  lymphatic  stream. 
Minimize  this  strain  and  teach  patients  the  importance  of  keeping  the 
skin  free  from  abrasions. 


Introduction  13 

Many  a  system  has  been  taxed  by  repeated  manicures  when  a  care- 
less  person  has  left  the  cuticle  bleeding  or  raw.  We  have  all  seen  cases 
where  the  fingers  were  a  bit  swollen  and  angry  looking  from  too  close 
cutting  of  the  cuticle  or  tearing  out  of  a  "hang  nail".  Slivers  allowed 
to  fester  tax  the  lymphatic  system  in  that  region.  Absorption  following 
abrasions  is  always  constant  and  present,  and  a  cat  or  dog  scratch  may 
show  up  at  distant  nodes  and  cause  a  systemic  poisoning  that  may  pro- 
duce anorexia  or  nausea,  if  not  more  serious  result. 

There  are  no  such  things  as  trifles  in  the  way  of  abrasions.  Septic 
poisoning  even  in  a  small  degree  may  follow.  Some  are  heedless  to 
abrasions  and  only  laugh  at  them,  and  give  them  no  attention.  Little 
has  been  written  upon  this  subject  for  the  lay  mind  and  therefore  a  lot 
of  systemic  disorders  have  gone  by  unnoticed.  It  is  only  when  evi- 
dences of  blood  poison  are  noticed  that  people  begin  to  think  of  the 
seriousness  of  an  infected  abrasion.  To  my  mind,  proper  care  of  the 
skin  is  most  significant  if  the  body  is  to  be  kept  up  to  a  normal  standard. 

Fortunatel}',  gum  boils  are  no  longer  laughed  at  or  scorned,  but 
people  have  their  teeth  X-raj-ed,  thanks  to  progressive  dentists  and 
physiciajps. 

In  the  following  chapters  we  intend  taking  up  the  applied  refer- 
ences to  1st,  the  head  and  neck;  2nd,  the  region  of  the  intercostals,  and 
3rd,  the  abdominal  and  pelvic  regions.  We  illustrate  these  chapters 
with  original  drawings. 


The  Editor 
A.  G.  WALMSLEY,  D.  O. 


EDITOR'S  PREFACE 

It  has  been  my  privilege  to  be  closely  associated  with  Dr.  Millard 
and  his  work  for  a  number  of  years.  Six  or  more  years  ago,  before  he 
had  written  on  the  subject  of  Lymphatics,  he  outlined  to  me  his  theories 
of  lymphatic  diagnosis  in  certain  pathological  conditions.  At  first 
the  thought  was  new  and  I  was  inclined  to  be  skeptical,  but  as  the  sub- 
ject opened  up  I  began  to  see  the  logic  of  the  theory.  Since  then  Dr. 
Millard  has  given  much  time  to  the  study  of  the  lymphatic  system,  and 
this  work  is  the  outcome  of  his  studies  and  researches. 

The  first  five  chapters  of  the  book  are  by  Dr.  Millard.  In  these 
chapters  the  applied  anatomy  of  the  lymphatic  system  is  discussed  in 
the  various  parts  of  the  body.  These  chapters  merit  careful  study,  not 
only  because  they  present  many  valuable  thoughts  on  the  subjects  under 
discussion,  but  because  they  lay  the  foundation  for  a  better  understand- 
ing and  appreciation  of  the  thoughts  presented  in  later  chapters  by  other 
writers. 

Dr.  Millard's  penchant  for  illustrating  his  writings,  and  the  at- 
tractive, convincing  manner  in  which  he  does  it,  has  always  made  his 
writings  highlj'  acceptable  to  the  profession.  In  the  present  volume 
no  effort  nor  expense  has  been  spared  in  this  respect,  and  the  value  of 
the  work  is  greatly  enhanced  because  of  the  graphic  manner  in  which 
it  is  illustrated. 

While  the  title  of  the  work  is  Applied  Anatomy  of  the  Lymphatics, 
it  contains  so  much  new  and  valuable  data  on  the  treatment  of  the  lym- 
phatics that  no  busy  and  progressive  practician  can  afford  to  be  with- 
out it.  Some  of  the  specialists  who  contribute  to  the  work  devote  as 
much  or  more  attention  to  a  discussion  of  treatment  as  they  do  to  anat- 
omy, but  it  is  worthy  of  note  that  in  every  instance  they  first  review  the 
anatomy  of  the  part  in  order  that  they  may  emphasize  the  anatomical 
reasons  for  the  treatment  outlined. 

In  bringing  out  this  work,  it  is  not  claimed  that  the  last  word  has 
been  said  on  the  subject  presented,  or  on  any  phase  of  the  subject.  It 
is  in  the  nature  of  research  work,  and  it  is  hoped  from  time  to  time  to 
add  new  facts  to  our  knowledge  of  the  lymphatic  system. 

A  glance  at  the  chapter  headings  may  create  the  impression  that 
there  is  much  repetition  in  the  work,  but  this  is  not  so.  Each  writer 
presents  his  subject  in  a  different  way,  and  each  writer  brings  out  and 
emphasizes  facts  not  brought  out  by  the  other  writers. 

The  attitude  of  the  average  physician  toward  the  subject  of  lym- 
phatics is  one  of  aloofness.     It  is  too  intricate  for  him;  it  would  require 

—15— 


16  Lymphatics 

more  study  than  he  could  afford  to  devote  to  it,  he  thinks.  Now,  this  is 
not  so;  it  only  seems  so.  I  am  happy  to  say  that  the  subject  as  pre- 
sented  in  this  book  is  not  only  easy  to  understand,  it  is  simple  and  at- 
tractive. Indeed,  the  subject  is  so  attractively  presented  that  the  phy- 
sician in  perusing  it  will  be  doubly  repaid  in  that  he  will,  while  being 
edified  on  the  subject  of  lymphatics,  at  the  same  time  get  a  splendid 
review  of  general  anatomy. 

The  past  few  years  have  witnessed  what  might  almost  be  termed  a 
revival  of  faith  or  belief  in  the  principles  on  which  the  science  of  Oste- 
opathy is  founded.  There  were  those  who  faltered,  who  were  carried 
away  by  the  siren  call  of  other  systems,  especially  the  drug  system. 
This,  really,  was  a  passing  phase  in  our  professional  and  scientific  growth, 
a  sort  of  "growing  pain."  The  underlying  reason  for  such  defections 
is,  that  many  of  our  profession  spend  much  time  delving  into  medical 
texts  and  little  time  pondering  the  writings  of  the  founder  of  Osteopathy 
and  of  other  capable  writers  in  our  ranks.  It  is  well  to  know  medical 
theorj%  but  if  we  would  attain  the  highest  measure  of  success  in  our 
practice,  we  must  be  firmly  grounded  in  the  osteopathic  theory  and  the 
application  of  that  theory.  To  accomplish  this  we  must  study  osteo- 
pathic books. 

The  osteopathic  physician  who  will  study  this  work,  Applied  Anat- 
omy of  the  Lymphatics,  will  understand  better  than  ever  before  why  he 
succeeds  in  certain  types  of  cases  where  other  systems  fail;  he  will  under- 
stand better  why  Osteopathy  is  so  successful  in  handling  acute  dis- 
eases; he  may  understand  why  he  has,  in  the  past,  .secured  results  in 
certain  conditions  without  knowing  just  why  results  were  secured. 

Applied  Anatomy  of  the  Lymphatics  is  osteopathic  through  and 
through.  In  many  pathologic  conditions  it  tells  us  what  to  do,  and, 
what  is  equally  important,  it  also  tells  us  what  not  to  do.  This  book 
should  be  in  the  hands  of  everj^  physician  in  practice  and  every  student 
in  our  colleges.  It  is  not  only  a  worthy  contribution  to  our  literature,  it 
also  marks  another  milestone  in  osteopathic  progress. 

A.  G.  Walmsley,  D.  O. 
Bethlehem,  Pennsylvania, 
March,  1922. 


CHAPTER  ONE 

THE  LYMPHATIC  SYSTEM 

APPLIED  ANATOMY 
General  Outline 

Students  of  anatomy  sometimes  fail  to  grasp  the  relative  importance 
of  collecting  applied  data  as  compared  to  that  of  gaining  a  knowledge 
of  the  tissues,  organs  and  general  framework  of  the  human  body  as  out- 
lined  in  texts  on  that  subject. 

The  physician  in  practice  soon  feels  the  need  of  greater  knowledge 
of  the  various  vessels,  nerves  and  organs  along  the  line  of  applied  con- 
cept. As  he  advances  in  his  work  and  studies  his  patients  at  the  office 
and  bedside,  there  comes  a  longing  to  know  just  what  relation  exists 
between  the  various  parts  of  the  body  and  the  disease  that  he  is  endeavor- 
ing to  diagnose.  He  wonders  always,  or  should,  how  great  an  involve- 
ment is  present  in  certain  disorders  where  symptoms  reveal  specific 
pathological  phases.  In  neuritis,  for  instance,  he  asks  what  change  has 
taken  place  that  has  caused  a  normal  nerve  tone  to  be  replaced  by  the 
symptoms  so  strikingly  impressed  upon  the  patient.  He  had  been 
taught  in  college  the  general  outline  of  the  nerve  tracts,  their  nerve  root 
tracings  and  their. relation  to  the  groups  of  muscles.  He  also  was  taught 
the  osseous  framework  and  the  relation  of  the  nerves  to  the  various  bones. 
But  in  some  instances  he  had  never  worked  out  in  detail  the  applied  part 
and  felt  that  he  did  not  understand  the  various  stages  of  muscle  tension 
as  related  to  nerve  instability  and  irritability.  The  various  causes  of 
the  chemical  changes  in  the  body  fluids  in  perverted  function,  such  as 
the  possibility  of  lymph  blockage  through  the  malposition  of  certain 
bones,  and  the  resultant  organic  disorders  that  follow  a  perverted  blood 
supply  to  the  walls  or  substance  of  an  organ,  and  the  lack  of  vasomotor 
control  in  some  instances.  As  osteopathic  physicians,  we  are  more  or 
less  familiar  with  this  follow  through  system,  and  we  reason  from  cause 
to  effect.  We  have  familiarized  ourselves  with  the  general  blood  cir- 
culation both  from  an  anatomical  and  physiological  standpoint,  and 
then  the  pathological. 

Applied  anatomies  have  been  written  both  from  a  surgical  and  os- 
teopathic standpoint  that  deal  with  many  phases  from  a  very  practical 
viewpoint.  From  these  books  we  have  learned  much  although  we  are 
yet  in  our  infancy,  so  to  spealc,  as  to  the  real  significance  of  applied  work. 

As  mentioned  in  the  preface  no  attempt  as  yet  has  been  made  to 
devote  a  book  to  the  subject  of  the  lymphatics  in  all  its  various  phases. 

—17— 


18  Lymphatics 

In  dealing  with  the  lymphatics  first  from  an  applied  anatomy  stand- 
point, we  do  not  claim  in  any  way  to  be  adding  any  new  anatomical 
features,  but  we  hope  to  enable  the  student  to  get  a  mental  picture  of 
the  various  structures  so  that  he  will  more  readily  grasp  the  significance 
of  the  causation  of  disorders  in  the  body  when  symptoms  manifest  them- 
selves. 

We  want  to  emphasize,  in  considering  the  lymphatic  system,  the 
importance  of  any  perversion  of  the  tissues  that  may  alter  the  function 
of  any  part  of  the  body. 

In  the  various  regions  discussed,  we  hope  to  assist  the  student  in 
clarifying  the  various  influences  that  may  have  a  bearing  upon  the  struc- 
tures affected  thereby  producing  tissue  changes  to  the  extent  of  causing 
some  bodily  disturbance. 

The  lesion  theory  as  propounded  by  Dr.  A.  T.  Still,  will  be  given 
first  place  in  all  our  discussions,  because  we  know  that  his  reasonings 
were  correct  and  can  be  demonstrated  in  any  instance  where  there  re- 
mains sufficient  impulses  to  carry  out  this  idea. 

We  realize  there  are  certain  diseases  so  far  advanced  that  the  re- 
flexes are  lost  and  the  nerve  impulses  so  disturbed  or  feeble  that  it  is 
quite  impossible  to  restore  normal  functioning,  but  these  cases  are  ex- 
treme,  and  we  will  consider  more  particularly  those  cases  that  are  amen- 
able to  adjustment  and  restoration. 

In  dealing  with  the  lymphatic  system,  let  us  go  about  it  in  a  man- 
ner that  will  first  of  all  be  broad  enough  in  outline  to  realize  that  the 
body  is  a  machine  that  is  so  correlated  that  if  one  part  suffers  there  will 
be  a  corresponding  reflex  that  will  to  some  degree,  at  least,  affect  other 
parts  or  all  parts. 

The  tendency  of  the  day  is  to  specialize  and  narrow  ourselves  to 
the  point  of  believing  that  any  organic  disturbance  is  a  localized  one, 
and  that  we  must  treat  or  deal  with  the  affected  part  from  a  local  stand- 
point. This  must  be  overcome,  and  we  must  fix  in  our  minds  the  fact 
that  the  circulation  that  bathes  one  part  of  the  body  one  minute  may 
be  bathing  a  remote  part  a  little  later;  that  the  lymphatic  system  is 
so  arranged  that  the  drainage  continues  to  the  point  of  emptying.  The 
blockage  at  a  point  in  the  abdomen  or  pelvis  will  reflect  itself  upon  the 
lymph  flow  possibly  in  the  feet.  We  can  also  see  how  enlarged  glands 
in  the  neck  may  cause  any  number  of  disturbances  in  the  organs  of 
special  sense  in  the  head. 

Insufficient  stress  has  been  laid  upon  the  points  of  interference  with 
the  flow  of  lymph,  and  in  these  chapters  on  applied  anatomy  we  hope 
to  show,  in  some  degree,  the  possibilities  of  many  diseases  being  existent 
through  a  blockage  of  the  lymph  flow  either  in  the  nodes  or  vessels; 


The  Lymphatic  System  19 

Finally,  we  want  to  assist  the  student  by  demonstrating  that  in 
any  pathological  condition  there  is  invariably  a  relative  lymphatic  dis- 
turbance, and  try  to  show  how  adjustment  will  assist  the  body  in  clear- 
ing up  the  retardation  or  obstruction. 


NEW  METHOD  OF  DIAGNOSING  VARIOUS  DISEASES  BY 
PALPATING  LYMPHATIC   GLANDS* 

(Reprint  of  article  by  author  from   the  Journal  of  the  American  Osteopathic  Association,  Julj%  1920) 

Had  Dr.  A.  T.  Still  lived  a  few  years  longer  I  sincerely  believe  he 
would  have  given  to  the  world  a  vast  amount  of  information  regarding 
the  lymphatic  system.  I  have  always  felt  that  he  had  in  his  mind  some 
information  along  the  line  of  new  physiology  dealing  with  this  subject. 
He  hinted  at  the  reduction  of  obesity  by  lymphatic  control,  and  often, 
mentioned  the  lack  of  knowledge  and  research  in  relation  to  the  lym- 
phatics, but  we  could  never  draw  any  definite  conclusions  as  to  his  reason- 
ings.  One  day,  twenty -three  years  ago,  I  ventured  to  ask  him  regarding 
the  significance  of  the  lymphatic  system,  but  -he  passed  the  subject, 
by  simply  stating  that  he  was  still  experimenting  along  that  line. 

Recognizing  that  there  was  a  field  only  partially  worked  out,  I  set 
about  to  determine  if  I  could  discover  any  hidden  truth  that  might  be 
of  value  to  the  osteopathic  profession.  My  first  observations  were  re- 
warded, some  sixteen  years  ago,  by  a  revelation  that  gave  me  grounds 
for  further  research.  The  idea  was  so  new  I  did  not  feel  like  announc- 
ing it  until  I  had  satisfied  myself  that  there  was  sufficient  merit  in  the 
theory  to  warrant  its  publication. 

Three  times  during  the  past  few  years  I  have  ventured  to  throw  out 
a  few  suggestions.  One  reference  to  the  matter  pertained  to  swellings 
found  in  the  breast  and  their  relation  to  axillary  disturbances;  a  second 
was  the  inguinal  disturbance  found  in  the  right  groin  in  cases  of  ap- 
pendicitis; and  the  third,  published  in  the  May  number  of  this  Journal, 
dealt  with  enlargement  of  the  lymphatic  glands  from  outside  infections 
and  inoculations. 

Allow  me  to  state  that  I  believe  that  few,  if  any,  physicians  have 
made  it  a  regular  part  in  their  diagnostic  work,  year  in  and  year  out,  to 
carefully  examine  the  condition  of  the  various  lymphatic  glands  as  a 
part  of  their  examination  of  patients,  also  the  following  up  of  the  state 
of  these  glands  from  time  to  time  in  cases  where  lymphatic  enlargement 
was  found.     This  calls  for  the  development  of  a  peculiar  touch,  as  pal- 

♦First  publication  of  the  technique  of  tlie  newest  thing  in  diagnosis — and  it  is  OSTEOPATHIC. — 
Editor,  Journal  of  the  American  Osteopathic  Association. 


20  Lymphatics 

pable  glands  vary  so  much  in  different  systemic  conditions  that  it  is 
ahnost  incredible  the  number  of  phases  these  nodules  assume. 

For  several  years  I  have  based,  almost  conclusively,  my  diagnosis 
as  to  the  surgical  or  nonsurgical  nature  of  the  appendix  upon  the  state 
in  which  I  found  the  inguinal  glands.  They  serve  as  an  index  to  the 
pathological  condition  existing  around  the  caecum  and  appendix. 

As  stated  above,  I  almost  hesitate  to  announce  this  new  method  of 
diagnosis  and  suggest  that  you  will  not  criticise  too  severely  until  you 
have  gone  through  a  period  of  personal  findings,  and  have  satisfied  your- 
self as  to  the  merit  of  the  method.  I  shall  not  try  to  cover  in  this  article 
all  of  the  diseases  in  which  lymphatics  are  disturbed,  but  simply  refer 
to  three  or  foiu-  disturbances,  and  leave  it  to  you  to  think  over  and  ex- 
periment for  yourself. 

Going  back  to  appendicitis,  let  me  state  that  you  will  first  have  to 
familiarize  yourself  with  the  various  conditions  found  in  the  inguinal 
region.  It  is  well  to  always  palpate  carefully  both  groins,  first  with 
the  limbs  extended,  and  then  flexed.  When  the  limbs  are  extended,  the 
glands,  if  present  and  enlarged,  will  present  a  different  feeling  than  when 
the  knees  are  bent. 

The  subject  has  so  many  phases  that  I  find  it  difficult  to  describe 
in  a  brief  article  the  thoughts  that  will  bring  out  the  most  striking  fea- 
tures. About  the  first  thing  that  you  will  suggest  is  the  question.  How 
can  you  differentiate  when  there  is  a  pelvic  congestion,  such  as  when  a 
right  ovary  or  tube  is  involved ;  also,  how  can  you  distinguish  if  there  ex- 
ists an  infection  of  a  venereal  nature.  To  say  that  it  is  easy  would  be 
foolishness,  but  to  state  that  skill  will  follow  long  research  would  be 
on  a  par  with  the  statement  that  months  of  practice  are  often  necessary 
for  the  student  to  detect  some  hidden  spinal  lesions. 

We  are  all  quite  familiar  with  the  almost  set  type  of  glandular  in- 
guinal enlargement  found  in  gonorrhea,  for  instance.  The  nodules  are 
usually  quite  enlarged  and  often  indurated.  They  ebb  and  flow,  so  to 
speak,  as  the  disease  is  acute  and  active,  or  subside  with  lack  of  conges- 
tion in  the  sexual  organs. 

I  will  admit  that  one  difficult  diagnosis  to  make  is  when  appendicitis 
is  conjointly  found  with  venereal  infection.  Should  there  be  simple 
ovaritis  or  salpingitis,  with  no  venereal  '"nfection,  we  usually  find  a  dis- 
turbed lymphatic  condition,  accompanied  with  certain  reflexes.  Ovarian 
colic  or  cramps,  or  a  hypersensitive  hypogastric  plexus  will  enable  the 
examiner  to  determine  the  presence  of  tubal  congestion. 

In  a  case  of  appendicitis,  with  apparently  no  complications,  if  pus 
is  present  and  the  caecal  area  is  involved,  the  inguinal  glands  are  found 


The  Lymphatic  System  21 

slightly  elevated  and  their  nodular  surfaces  under  the  skin  readily  pal- 
pable. This  condition  I  have  almost  invariably  found  and  verified  by 
judging  as  to  the  advisability  of  referring  the  case  to  a  surgeon  on  the 
strength  of  the  amount  of  nodulation. 

In  a  test  covering  a  period  of  four  years,  some  seven  years  ago,  I 
treated  three  hundred  and  ten  cases,  with  the  result  that  three  had  to 
be  operated  upon  after  a  trial  to  reduce  congestion.  That  was  a  small 
percentage.  At  one  time  I  was  treating  eight  cases  that  had  been  told 
to  be  operated  upon  within  twenty-four  or  forty-eight  hours.  This 
strain  was  not  small,  as  I  appreciated  the  significance  of  the  situation. 
Fortunately  I  was  rewarded  by  bringing  these  eight  cases  out  of  danger, 
and  I  followed  up  the  acute  attacks  with  corrective  work.  I  relied  en- 
tirely upon  my  diagnosis  in  relation  to  the  inguinal  glands. 

In  the  March  number  of  the  A.  O.  A.  Journal,  1916,  there  is  a 
colored  plate  showing  the  Ijonphatic  glands  of  this  region.- 

The  breast  region  is  also  a  most  significant  one,  in  that  the  axillary 
region  is  so  directly  concerned.  Surgical  operations  for  removal  are  so 
ver>'  common  that  one  almost  wonders  where  it  will  end.  It  is  not  un- 
common to  find  lumps  or  swellings  in  one  or  both  breasts.  The  signifi- 
cance of  these  tumors  depends  upon  the  amount  of  lymphatic  involve- 
ment of  a  general  nature. 

If  you  will  carefully  trace  the  channels  back  to  the  axilla  in  rela- 
tion to  the  pectoral  muscles,  you  can  quite  readily  determine  the  amount 
of  glandular  involvement.  If  the  axillary  region  is  comparatively  clear 
of  nodules,  and  there  seems  to  be  no  particular  blocking  of  the  connect- 
ing  channels,  it  is  usually  safe  to  say  that  the  lumps  found  in  the  breast 
are  not  of  a  malignant  type,  and  may  be  reduced  indirectly  by  corrective 
work.  As  a  rule,  malignancy  of  the  breast  follows  axillary  warning  of 
some  duration.  Traumatic  injuries  of  the  breast  should  be  attended  to 
at  once,  as  the  tendency  is  toward  circumscribed  induration,  with  sec- 
ondaiy  lymphatic  complications. 

Possibly  the  most  patent  instance  of  lymphatic  abnormality  is 
found  in  the  throat. 

We  are  all  familiar  with  the  "kernels,"  "lumps,"  and  peculiar 
nodular  enlargements  found  in  children  as  well  as  in  adults  accompany- 
ing various  epidemics  and  tonsillar  infections.  In  children  we  have  a 
range  of  swollen  glands,  from  those  found  preceding  measles,  chicken- 
pox,  etc.,  to  those  noted  in  scrofular  and  tubercular  diseases.  Accom- 
panying a  simple  rhinitis  we  often  note  a  marked  disturbance,  while 
in  tonsillitis,  even  in  the  adult,  there  may  be  a  most  aggravated  Ij^mphatic 
disturbance. 


22  Lymphatics 

One  more  instance  and  we  will  close  this  abbreviated  article. 

The  final  reference  is  to  septic  infection  of  the  lymphatics  of  the 
popliteal  space  by  absorption  of  material,  including  perspiration,  dirt, 
and  dyes  from  stockings,  through  soft  corns  and  skin  abrasions  between 
the  toes.  We  are  all  familiar  with  blood  poison  and  lockjaw  from  plantar 
punctures  by  rusty  products,  with  dirt  and  cloth  carried  into  the  wound. 
The  resulting  symptoms  may  include  lockjaw. 

Examining  carefully  the  popliteal  regions,  in  all  cases  where  a  gen- 
eral examination  is  made,  I  have  frequently  observed  enlargement  of 
these  glands  when  this  space  should  be  comparatively  clear.  Upon  re- 
moving the  stockings  or  the  socks,  as  the  case  may  be,  I  have  found  in  a 
number  of  instances  skin  abrasions  between  the  toes.  Through  these 
cracks  or  denuded  slits  perspiration,  dust,  or  dyes  are  constantly  beihg 
absorbed,  and  the  resultant  effect  is  noted  upon  the  nodules  in  the  space 
behind  the  knee.  After  instructions,  and  the  careful  healing  of  these 
tissues  between  the  toes,  I  have  noticed  the  disappearance  of  the  nodu- 
lar swellings. 

This  last  reference  does  not  pertain  to  the  diagnosing  of  a  hidden 
trouble,  as  in  the  instance  of  pelvic  and  breast  involvement,  but  carries 
out  my  idea  that  infection  of  a  part  is  invariably  manifested  by  nodular 
interference  at  the  nearest  gland  center. 

Some  other  time  I  may  write  on  other  findings,  especially  the  de- 
termining of  the  degrees  of  tuberculosis  by  lymphatic  enlargement,  ac- 
cording to  the  region  of  the  body  diseased,  but  I  have  given  you  my  ideas 
in  part  as  to  the  possibility  of  diagnosing  more  accurately  the  degree  of 
infection  or  accumulation  of  toxic  products  by  lymphatic  manifesta- 
tions. 

A  LYMPHATIC  EXAMINATION 

This  is  an  innovation.  We  have  been  accustomed  to  general  and 
special  examinations,  but  to  set  out  to  make  a  lymphatic  examination  is 
a  new  departure. 

We  have  made  a  chart  blank  that  outlines  the  points  where  the 
physician  is  most  likely  to  find  lymphatic  variations  and  disturbances. 

First  of  all,  let  us  consider  the  lymphatic  system  as  a  whole — a 
general  circulation,  yet  subsidiary  to  that  of  the  vascular  system. 

We  find  that  there  is  a  field  for  applied  anatomy  of  the  lymphatics 
just  as  of  other  tissues  of  the  body.  We  find  lymph  blockage  and  nodu- 
lar enlargements,  hyperplasia  and  adenitis,  also  in  some  instances  a 
backing  up  and  a  reverse  in  the  flow  of  lymph.  This  has  been  described 
in  connection  with  the  gastric  lymph  vessels  by  noted  surgeons. 


The  Lymphatic  System 


23 


Plate  I. 
Seven  points  of  palpation  in  making  a  IjTnphatic  examination. 


24  Lymphatics 

There  is  an  ebb  and  flow,  so  to  speak,  in  the  lymph  stream.  To  il- 
lustrate  this  point  we  will  note  that  when  there  is  mesenteric  blockage  or 
pelvic  lymph  nodular  adenitis  a  corresponding  distm-bance  is  found  in 
the  lymph  areas  of  the  popliteal  space;  also  a  slight  edematous  condi- 
tion in  the  ankles,  usually  on  the  outer  side  just  in  front  of  the  external 
malleolus.  Again  we  note  where  there  is  a  puffiness  above  the  clavicles, 
on  one  side  or  both,  a  corresponding  blockage  of  the  lymph  stream  exists 
either  at  the  emptying  point  of  the  thoracic  duct  and  right  lymphatic 
duct,  or  we  will  find  an  over-burdened  thoracic  duct  from  too  much  ten- 
sion or  too  great  an  accumulation  of  lymph.  The  system  is  constantly 
trying  to  clear  itself  and  the  clearing  house  is  partly  made  up  of  the  lym- 
phatic system. 

Again  we  note  a  pufl&ness  around  the  eyes.  There  is  a  cause  for 
it.  If  we  trace  the  lymph  stream,  we  will  soon  discover  that  there  is 
a  blockage  in  the  cervical  nodes,  or  possibly  the  submaxillary,  or  nodes  in 
the  parotid  region.  There  may  be  lesions  causing  tensed  muscles  that 
prevent  a  free  drainage.  In  all  of  the  lymph  nodes  and  vessels  in  the 
throat  and  neck  there  is  a  possibility  of  blockage. 

There  is  also  a  possibility  of  lymph  obstruction  through  the  en- 
largement of  the  salivary  glands  or  a  subluxation  of  the  mandible  or 
hyoid  bone.  The  puffiness  of  the  eyes  may  be  due  to  over-burdened 
kidneys,  and  an  enlarged  liver.  Disorders  of  the  spleen  may  also  cause 
it  when  the  system  is  loaded  with  toxic  products  and  elimination  is 
faulty.  We  may  look  then  for  a  lymph  stream  blockage  and  puffy  areas 
in  certain  regions.  Thus  we  see  it  is  well  to  examine  for  areas  of  lymph 
obstruction  where  there  are  evidences  of  edema. 

Now  that  we  have  this  viewpoint  in  mind,  let  us  proceed  to  make 
our  lymphatic  examination.  With  the  blank  before  us,  we  will  staii't 
always  at  the  emptying  points  of  the  lymph  tubes  or  ducts.  On  both 
sides  these  ducts  empty  into  the  subclavian  veins.  If  the  drainage  is 
fairly  perfect  there  will  be  no  puffiness  above  the  clavicles.  If  there 
is  a  blockage  or  over-loading,  we  will  observe  edema. 

Let  us  take  the  presence  of  edema  on  the  left  side  and  work  out 
our  examination  and  diagnosis.  The  second  point  we  will  note  will 
be  the  axillary  region  (No.  5).  Note  any  nodular  enlargement  or  ade- 
nitis, and  if  present  trace  out  the  cause.  See  if  there  has  been  a  recent 
scratch  or  abrasion  of  the  skin  on  arm,  forearm  or  hand.  If  there  has 
been,  note  the  presence  or  absence  of  pus  or  even  a  blister.  Also  note 
the  vasomotor  tone  in  the  entire  arm.  Cold  hands  affect  the  lymph 
stream.  Should  there  be  signs  of  a  recent  vaccination  or  serum  injection, 
determine  the  amount  of  axillary  adenitis  that  existed  at  the  time. 


The  Lymphatic  System  25 

Next,  palpate  over  the  mammary  region  and  note  enlargement  of 
nodes  and  extent  of  induration  if  present.  Connect  up  the  arm  and 
pectoral  regions,  lymphatically  speaking,  and  determine  which  area  was 
first  affected  and  to  what  extent. 

Note  carefully  what  quadrant  of  the  breast  is  nodulated,  and  whether 
they  are  deep  seated  nodes  or  superficial.  Go  over  the  thoracic  verte- 
brae and  costal  areas,  and  determine  the  number  and  significance  of 
lesions.  Adjustment  of  vertebral  and  costal  lesions  may  clarify  the 
nodular  enlargement  if  no  abrasions  or  recent  vaccine  or  serum  injec- 
tions have  taken  place.  We  will  go  back  to  the  neck  now  and  palpate 
for  superficial  and  deep  nodular  enlargements  (No.  6).  Note  presence 
or  absence  of  goitre,  and  determine  if  there  have  been  recent  symptoms 
of  laryngitis  or  pharyngitis.  The  presence  of  muscle  tension  and  venous 
stasis  will  be  of  value  in  tracing  the  lymph  blockage.  Corresponding 
bony  and  muscular  lesions  may  be  found,  and  lymph  nodes  enlarged  to 
the  extent  of  irritating  the  nerve  cords  in  the  neck.  If  there  exists  any 
congestion  of  tissues  due  to  tonsillitis,  abscessed  teeth  or  sinus  infec- 
tion, note  the  effect  on  the  cervical  lymph  nodes.  Determine,  if  possible, 
the  amount  of  lymph  suspended  and  retained  in  the  vessels  and  nodes 
at  all  points  above  the  hyoid  region  (No.  7).  After  testing  and  palpating 
the  various  nodes  and  edematous  areas,  including  the  tonsillar  and 
faucial  areas,  try  and  determine  the  relation  of  this  blockage  to  that 
found  in  the  terminal  area,  back  of  and  above  the  clavicles. 

Again,  we  note  the  lack  of  drainage,  if  present,  from  the  broncho- 
mediastinal trunks.  Following  bronchitis  or  a  pleuritic  infection, 
there  may  be  a  difficult  drainage  that  will  reflect  itself  upon  the  tissues 
above  the  clavicles.  How  often  in  throat  and  bronchial  troubles  we 
note  not  only  cervical  nodular  enlargement,  but  that  peculiar  puffiness 
above  the  clavicles  which  is  so  hard  to  reduce  unless  we  reason  out  just 
why  this  blockage  exists,  and  drain  the  lymph  vessels. 

In  this  brief  chapter  we  must  necessarily  point  out  only  a  few  of 
the  cardinal  points.  A  thorough  examination  including  all  applied  anat- 
omy findings  would  fill  a  book. 

We  will  recall  our  anatomy  teaching  regarding  the  collection  of 
lymph  on  the  two  sides.  This  will  explain  the  suggestion  just  made 
that  more  often  we  find  edema  in  the  left  supraclavicular  region. 

The  epigastric  region  we  will  next  discuss  briefly  (No.  4)  The 
liver,  from  a  lymphatic  standpoint,  is  more  significant  than  the  spleen. 
The  tendency  of  the  liver  to  enlarge  and  become  torpid  and  sluggish 
makes  lymph  drainage  uncertain.  Part  of  the  liver's  drainage  is  above, 
and  eventually  empties  into  the  right  lymphatic  duct  or  indirectly  into 


26  Lymphatics 

the  thoracic  duct  in  part.  The  principal  lymph  vessels  drain  into  the 
thoracic  duct  along  with  the  drainage  of  the  stomach. 

If  the  patient  is  thin,  you  will  observe  on  palpation  a  peculiar  en- 
largement of  the  receptaculum  chyli  when  the  knees  are  flexed.  Some- 
times you  can  palpate  the  larger  nodes  and  you  can  press  the  abdominal 
aorta  so  readily  against  the  receptaculum  chyli  that  you  can  cause  the 
pulse  beat  to  fluctuate.  I  have  palpated  the  receptaculum  chyli  when 
it  could  almost  be  picked  up  with  the  finger  tips  in  a  thin  person  when 
there  was  a  heavy  mesenteric  blockage. 

Splanchnoptosis  and  venous  stasis  combined  with  ovarian  con- 
gestion or  appendicitis,  will  soon  prove  to  you  the  great  amount  of  block- 
age that  takes  place  in  the  receptaculum  chyli  and  thoracic  duct. 

In  pelvic  congestion  the  nodes  are  markedly  enlarged,  as  you  will 
determine  by  special  local  examinations,  vaginal  and  rectal.  The  in- 
guinal glands  (No.  3)  will  reflect  not  only  pelvic  congestion  but  appendi- 
citis. The  lymph  blockage  of  the  mesenteric  glands  and  in  the  recep- 
taculum chyli  will  reflect  itself  upon  the  inguinal  glands  by  a  blockage 
of  lymph. 

Lastly,  we  will  go  briefly  over  the  lower  extremities.  Palpate  over 
the  popliteal  space  (No.  2)  with  patient  on  the  back,  and  then  with  pa- 
tient standing.  You  will  find  a  new  viewpoint  when  you  make  this 
double  test. 

Look  for  varicose  veins,  even  small  ones;  also  palpate  the  calf  mus- 
cles deeply  between  thumb  and  fingers  and  determine  presence  or  ab- 
sence of  stasis.  Recently  I  noticed  a  h^mph  disturbance  in  inguinal 
region  due  to  a  bruise  on  the  thigh;  also  a  popliteal  lymph  enlargement 
due  to  a  soft  corn.  Go  over  the  ankles  (No.  1)  and  look  for  any  swelling 
that  would  indicate  a  lymph  blockage  higher  up.  Again,  note  vasomotor 
tone  in  blood  vessels  and  observe  the  effect  upon  the  lymph  nodes  in 
popliteal  and  inguinal  regions. 

Summary 

1.  For  ever}'  congested  tissue  there  is  a  corresponding  lymph  dis- 
turl)ance. 

2.  Wherever  pus  is  present  there  is  enlargement  in  the  nearest 
nodes. 

3.  An  abscessed  tooth  or  even  a  pimple  or  small  boil  will  reflect 
itself  on  the  nodes. 

4.  The  IjTTiph  stream  ebbs  and  flows  according  to  the  amount  of 
blockage  and  nodular  enlargement  at  certain  points. 

5.  Edema  is  significant  of  lymph  blockage. 


The  Lymphatic  System  27 

6.  Nodular  enlargement  is  not  always  between  the  terminal  lymph 
drainage  and  distant  disturbance. 

7.  There  may  be  a  backing  up  of  lymph  and  a  reverse  flow  in  spite 
of  the  numerous  valves. 

8.  Collateral  lymph  circulation  may  take  place  when  indurated 
nodes  or  blocked  Ij^mph  channels  exist. 

9.  There  is  a  direct  and  an  indirect  vasomotor  control  of  the  lymph 
stream. 

10.  Enlarged  nodes  may  irritate  or  over-stimulate  nerve  trunks. 

11.  Vaccines  and  serums  are  as  direct  causes  of  nodular  involve- 
ment as  poisons  taken  into  the  system. 

12.  The  lymph  stream  must  always  be  drained  first  through  the 
terminal  areas. 

13.  Attempts  to  clear  the  lymph  stream  before  clearing  the  edema 
in  the  clavicular  regions  is  to  over-tax  the  general  lymph  stream  and 
cause  profound  reactions. 

14.  Any  permanent  results  in  treating  the  lymphatics  must  be 
accompUshed  through  the  nerve  centers  that  control  the  vasomotor 
nerves  of  the  blood  vessels  in  the  same  region  as  the  lymph  blockage. 

15.  Never  work  over  an  enlarged  or  indurated  lymph  node — free 
the  efferents  and  the  lymph  will  drain. 

16.  General  exercises  will  stimulate  lymph  flow,  but  if  there  is 
marked  lymph  blockage  it  is  better  to  relieve  the  lymph  tension  before 
exercises  are  given.     This  will  save  marked  reactions. 

17.  In  treating  the  extremities,  see  that  the  axillary  and  inguinal 
regions  are  cleared  first. 

18.  The  only  way  to  clear  bronchomediastinal  lymph  blockage  is 
through  cervical  and  thoracic  adjustment.  Deep  control  can  only  be 
reached  in  that  manner. 

19.  Indurated  nodes  maj^  never  reduce.  Establish  drainage  and 
collateral  flow  will  follow. 

20.  Note  from  time  to  time  the  various  accessible  lymph  areas  in 
any  and  every  organic  disturbance. 

21.  Learn  to  palpate  nodes  in  every  region  where  they  are  ac- 
cessible. 


28  Lymphatics 

VENOUS  STASIS  AND  LYMPH  BLOCKAGE 

In  school  we  used  to  spend  a  few  days  on  the  subject  of  lymphatics. 
Five  years  from  now,  or  less,  students  will  receive  daily  instruction  on 
this  subject.  It  will  be  embodied  in  texts  on  applied  anatomy,  and  each 
organ  and  area  will  be  considered  from  a  lymphatic  standpoint.  Under 
the  discussion  of  every  diseased  organ  or  tissue  a  few  paragraphs  will  be 
included  referring  to  lymph  drainage.  We  have  devoted  much  time 
in  the  past  to  a  study  of  the  vascular  system  in  all  its  details,  but  have 
neglected  to  a  great  extent  the  tracing  of  lymph  flow  and  in  accounting 
for  edematous  areas  that  indexed  the  amount  of  venous  stasis  and 
lymph  blockage  that  existed.  We  have  paid  so  little  attention  to  the 
lymph  stream  that  we  have  not  gone  beyond  a  few  findings  in  two  or 
three  regions,  usually  the  cervical,  axillary  and  inguinal. 

Let  us  spend  a  few  minutes  going  over  the  principal  findings  that 
should  be  included  in  everj-  examination,  and  at  every  treatment.  In 
the  first  place,  wherever  there  is  venous  stasis  there  is  bound  to  be  hin- 
phatic  disturbance. 

We  will  take  the  mesenteric  region  first.  We  recall  the  innerva- 
tion and  vasomotor  control  of  the  vessels  in  this  area. 

With  the  osseous  lesions  that  may  cause  an  interference  with  per- 
istaltic action,  secretion  and  vasomotor  control,  we  are  familiar.  If 
there  is  ptosis  and  stasis  we  must  naturally  expect  lymph  blockage. 
The  receptaculum  chyli  that  drains  this  region  is  readily  blocked  when 
the  above  conditions  exist.  We  cannot  expect  to  correct  these  changes 
in  blood  and  lymph  streams  unless  we  first  of  all  correct  the  ptosis.  Or- 
gans that  have  sagged  cause  pressure  on  vessels  and  lymph  channels. 
Neither  can  we  expect  to  free  lymph  drainage  unless  there  is  a  normal 
thoracic  duct  passage.  If  there  exists  a  puffiness  back  and  above  the 
clavicle  on  left  side  we  must  see  that  the  edema  is  reduced  before  we  at- 
tempt drainage  at  a  point  in  the  region  of  the  receptaculum  chyli.  This 
will  necessitate  correction  of  lesions  from  the  cervical  area  down  to  the 
pelvis.  It  would  be  useless  to  correct  cervical  and  thoracic  lesions  if  a 
sacrum  was  tilt<^d  sufficiently  io  cause  an  unbalanced  spine.  We  must 
also  work  to  restore  normal  impulse  to  the  mesenteric  vessels  in  order 
that  venous  stasis  will  disappear.  NoiTnal  relations  will  come  about 
only  by  correction  of  all  lesions  causing  ptosis  and  misplacement.  A 
sagged  stomach  dragging  over  the  thoracic  duct  and  receptaculum  chylj 
will  interfere  with  lymph  drainage. 

Venous  stasis  must  be  cleared  up  by  securing  first  of  all  a  normal* 
liver  condition.     Any  lesions  affecting  the  various  functions  of  the  liveav^ 


The  Lymphatic  System  29 

will  check  the  clearing  of  the  veins  and  lymph  vessels.  It  is  in  this 
region  that  we  find  the  many  tumors,  benign  and  malignant.  The  lym- 
phatics are  involved,  the  nodes  enlarged,  and  lymph  vessels  obstructed. 
If  you  want  to  see  this  object  lesson  make  a  few  post  mortems  in  cancer 
of  stomach  or  associated  parts  and  observe  the  lymph  blockage. 

While  venous  stasis  is  relatively  important,  yet  we  believe  lymph 
blockage  the  more  significant  in  foreign  growths  and  in  congestion. 

While  venous  stasis  may  precede  lymph  blockage,,  yet  it  is  the  lymph 
disturbance  that  spells  disaster  to  the  tissues.  In  the  final  analysis 
the  veins  are  much  less  important  in  relation  to  a  pathological  phase 
than  are  the  lymph  vessels  and  nodes.  It  is  easier  to  re-establish  venous 
drainage  than  lymph  drainage. 

The  nodes  once  enlarged  and  indurated  are  not  easily  reduced. 
True,  the  lymph  vessels  have  valves  more  numerous  than  the  veins, 
but  they  also  have  a  lesser  calibre  and  the  lymph  flow  is  constantly 
checked  by  the  flow  through  the  nodes.  While  some  nodes  have 
vasomotor  nerve  fibres,  the  blood  vessels  are  much  better  supplied  with 
these  fibers.  Thus  we  have  to  contend  in  lymph  blockage  first,  with  a 
venous  stasis  that  must  be  cleared,  then  a  lymph  drainage  that  must 
include  a  reduction  of  the  nodes  when  enlarged,  and  a  free  lymph  flow 
at  the  terminals  of  the  lymph  ducts.  The  blood  vessels  that  supply 
the  nodes  may  have  vasomotor  nerves,  but  we  must  depend  in  freeing 
the  lymph  stream  upon  indirect  vasomotor  control  through  the  nerves 
to  the  vascular  system.  The  vasomotors  to  the  nodes  are  not  con- 
stant. /Again,  in  order  to  clear  the  lymph  stream  in  the  mesenteric 
region,  we  must  consider  the  possibility  of  an  unusual  lymph  flow  from 
the  pelvic  region.  If  this  exists  there  will  be  found  an  additional  tax 
upon  the  receptaculum  chyli  from  the  lymph  below,  and  this  additional 
burden  upon  the  thoracic  duct  in  cases  of  pelvic  disturbance  will  make 
mesenteric  drainage  more  difficult. 

Normally,  the  receptaculum  chyli  and  afferent  ducts  are  sufficiently 
taxed,  but  abdominal  and  pelvic  venous  stasis  will  overtax  the  lymph 
stream  in  every  instance.  This  will  reflect  itself  upon  the  lymph  drain- 
age of  the  various  organs  in  this  region  and  only  the  insurance  of  a  nor- 
mal venous  and  Ij^mph  flow  will  clear  the  area  and  remove  the  tax  upon 
the  lymphatics  of  the  receptaculum  chyli. 

The  majority  of  ailments  of  the  human  body  have  their  beginning 
in  the  epigastric  region.  A  sluggish,  inactive  liver  may  start  a  stasis 
and  lymph  blockage  that  will  reflect  itself  upon  not  only  the  immediate 
organs  and  tissues  but,  by  blockage,  prevent  pelvic  drainage  of  the  lym- 
phatics.   We  will  then  note  a  little  puffiness  in  the  ankles,  a  similar 


30  Lymphatics 

condition  back  of  the  knees  in  the  popliteal  spaces,  and  unless  we  free 
the  ducts  and  chyli  nodes,  the  edema  will  persist. 

It  is  easy  to  block  drainage  below  the  second  lumbar  segment.  An 
obstructed  alimentary  tract  will  produce  lymph  blockage  very  nicely. 
A  lessened  vasomotor  tone  will  also  block  the  lymph  vessels  and  nodes 
when  venous  stasis  is  present. 

There  must  be  tone  and  there  is  only  one  way  to  get  tone,  and  clear 
the  congestion,  and  that  is  by  good  technique  and  specific  corrective 
work. 

You  will  recall  the  peculiar  vasomotor  control  in  the  mesenteric 
region.  The  second  relay,  so  to  speak,  to  give  extra  impulse  to  the 
mesenteric  vessels.  This  will  call  for  lesion  findings,  and  corrections 
higher  up  than  is  usually  found  in  other  organic  disturbances. 

It  is  well  to  re-read  anatomies  occasionally  and  keep  in  mind  the 
nerve  centers  that  control  the  vasomotors.  It  is  through  these  nerves 
that  we  make  headway  in  clearing  stasis  and  secondary  lymph  blockage. 

In  this  brief  chapter  we  can  discuss  only  one  region,  but  we  have 
tried  to  emphasize  a  fact  that  may  be  applied  to  any  lymph  area,  namely, 
that  a  venous  stasis  will  invariably  cause  a  lymph  blockage.  We  have 
not  included  in  this  chapter  conditions  where  lymph  obstruction  may  be 
primary,  such  as  direct  poisoning  of  the  system  through  introduction  of 
vaccines,  serums,  or  ptomaine  substances.  This  phase  of  the  subject 
must  be  dealt  with  from  a  different  angle. 


CHAPTER  TWO 

APPLIED  ANATOMY  OF  THE  LYMPHATICS  OF 
THE  HEAD  AND  NECK 

General  Statement 

The  arrangement  of  the  lymphatics  in  the  neck  are  such  that  there 
is  every  possibihty  of  a  checking  or  blocking  of  the  lymph  flow  through 
lesioned  vertebrae  or  muscular  tension. 

There  is  also  the  fact  that  the  blockage  of  lymph  nodes  or  vessels 
in  the  neck  produces  hyperplasia  of  the  lymph  tissues  in  the  head.  The 
deeper  neck  glands  may  be  enlarged  for  a  time  quite  distinct  from  the 
enlargement  of  the  more  superficial  glands. 

While  the  superficial  and  deep  glands  are  closely  connected,  and 
their  drainage  point  remains  the  same,  yet  through  throat  infections  or 
cervical  lesions  the  one  set  may  become  involved  before  the  other  is 
affected. 

The  relation  of  the  nodes  to  the  nerves  and  blood  vessels  is  signifi- 
cant. If  sufficiently  enlarged  they  may  produce  pressure  sufficient  to 
create  undue  stimulation  on  nerves  passing  through  the  neck,  resulting 
in  accelerated  heart  action  or  bronchial  and  gastric  irritation.  This 
may  be  a  new  application  or  viewpoint,  but  may  be  demonstrated  in 
the  clinic  room. 

The  enlargement  of  nodules  may  interfere  with  salivary  secretions 
through  pressure  and  cause  a  dry  mouth  or  lack  of  saliva.  Enlarged 
glands  may  block  the  capillaries  and  veins  and  produce  a  flushed  face. 
This  point  may  be  demonstrated  when  the  patient  has  a  cold  and  the 
glands  in  the  neck  and  under  the  rami  of  the  inferior  maxillary  are  en- 
larged. 

In  the  chapters  written  by  the  specialists  on  eye,  ear,  nose  and 
throat,  you  will  find  more  detailed  statements  regarding  these  points. 
In  this  chapter  we  outline  in  a  general  way  the  possibilities  of  interfer- 
ence and  blockage  through  lesions  in  the  same  respect  as  we  treat  Ij^mph 
flow  interference  in  the  chapters  dealing  with  the  rest  of  the  body. 

We  want  to  make  it  plain  that  in  order  to  correct  any  disturbance 
in  the  head  we  must  look  well  to  lymph  drainage  at  every  point  where 
there  is  a  possibility  of  obstruction. 

Lymphatics  of  the  Tongue 

The  tongue  has  more  nerves,  vessels,  lymphatics,  and  variety  of 
functions  than  any  organ  of  its  size  in  the  body.     The  lymphatic  drain- 

—.31— 


32  Lymphatics 

ago  of  the  tongue  includes  vessels  and  nodes  that  carry  away  the  lymph 
individually  and  collectively.  As  in  the  innervation  the  tongue  seems 
to  be  divided  into  sections,  so  in  the  lymph  vessels  the  drainage  is  quite 
distinct  and  separate,  yet  all  channels  lead  to  the  deep  cervical  glands 
in  the  region  of  the  beginning  of  the  two  carotid  branches  from  the  com- 
mon  arterial  trunk. 

The  submaxillary  lymph  nodes  collect  lymph  from  the  free  end  of 
the  tongue.  The  deep  cervical  nodes  collect  from  the  nodes  on  the 
hypoglossus  muscle.  These  later  lymph  channels  follow  the  ranine  vein. 
Beneath  the  epithelium  of  the  tongue,  the  Ijinphatics  have  their  begin- 
ning. In  the  base  of  the  tongue  the  lymph  vessels  connect  freely,  while 
in  the  free  portion  there  is  quite  a  distinct  individual  drainage. 

There  are  small  lymph  vessels  originating  in  the  muscle  of  the  tongue, 
l)ut  the  submucous  vessels  are  in  the  vast  majority.  This  lymph  net- 
work is  so  arranged  that  the  vessels  are  readily  drained  unless  there  is 
blockage  in  the  nodes,  especially  in  the  submaxillary  region.  The  sub- 
mental lymph  glands  receive  a  part  of  the  drainage.  Small  lymph  ves- 
sels from  the  tip  of  the  tongue  perforate  the  mylohyoid  muscle  in  some 
instances,  and  end  in  the  node  above  the  hyoid. 

The  lymph  nodes  just  above  the  omohyoid  receive  some  lymph 
vessels.  The  relation  of  these  lymph  vessels  to  the  hyoid  bone  and  the 
digastric  muscle  is  of  significance.  Lesions  affecting  the  position  of  the 
hyoid  bone  may  interfere  with  the  drainage  of  the  lymph,  while  lesions 
disturbing  the  innervation  of  the  digastric  nmscles  may  also  cause  lymph 
blockage.     This  applies  also  to  the  mylohyoid  muscle  referred  to  above. 

You  will  notice  by  Figure  2  that  the  drainage  from  the  apex  of 
the  tongue  ends  in  nodes  much  lower  than  does  that  from  the  base  of 
the  tongue.  Where  the  digastric  muscle  passes  in  close  proximity  to 
the  jugular  vein,  there  are  .nodes  receiving  considerable  drainage.  The 
contraction  of  this  muscle  unduly  causes  blockage  in  the  nodes  and  lymph 
vessels.  There  is  also  a  large  node  at  the  point  of  crossing  over  of  the 
omohyoid  at  the  jugular  vein:  the  inferior  node  of  internal  jugular. 
Lesions  affecting  the  innervation  of  this  muscle  or  subluxation  of  the 
hyoid,  may  cause  retardation  of  lymph  flow.  The  superior  deep  cervical 
nodes  collect  lymph  from  many  lymph  vessels  and  their  obstruction 
through  blockage  in  the  thyroid  gland  region  must  be  carefully  noted. 
The  drainage  from  the  tonsillar  region  is  closely  connected  with  that 
of  the  drainage  from  the  back  of  the  tongue.  This  will  account  for  en- 
largement of  certain  nodes  when  a  cold  or  sore  throat  is  found. 

As  stated  above,  the  nerves  to  the  tongue  are  unusually  numerous, 
and  the  vasomotor  supply   through   the   sympathetics    controlling   the 


Head  and  Neck 


33 


Plate  II.  liymphatic  drainage  of  the  Tongue. — (1)  Lymph  drainage  of 
pharyngeal  portion  of  tongue.  (2^  Lymph  vessels  on  margin  of  anterior 
two  thirds  of  tongue;  (3)  Collecting  lymph  vessels  of  tip  of  tongue.  (4) 
Submental  nodes.  (5)  Submaxillary  nodes.  (6)  lAinph  vessels  con- 
veying Ivmph  to  deep  cervical  nodes,  7.  (8)  Lower  deep  cervical  nodes 
receiving  lymph  vessels,  9. 


34  Lymphatics 

lingual  blood  vessels  is  a  point  not  to  be  overlooked.  The  lingual  veins 
are  readily  interfered  with  at  certain  points  and  if  stasis  or  edema  ex- 
ists there  will  be  interference  with  the  lymph  flow. 

Treatment 

To  regulate  the  vasomotor  control  of  the  blood  vessels  in  the  tongue, 
we  must  first  of  all  see  that  the  muscles  of  the  tongue  are  not  disturbed 
through  lesions  that  affect  the  innervation  of  these  muscles. 

Any  cervical  lesion,  or  even  upper  thoracic,  may  cause  a  vasomotor 
instability.  The  hyoid  bone  may  be  slightly  or  markedly  out  of  align- 
ment through  traumatism  or  extreme  lateral  muscular  tension.  Lesions 
affecting  the  scaleni  muscles  may  cause  costal  traction  of  the  first  or 
second  ribs  and  produce  a  blockage  of  the  lymph  at  or  near  the  terminals 
of  the  lymph  vessels.  The  slightest  amount  of  blockage  in  the  lymph 
nodes  and  vessels  will  back  up  or  check  the  drainage  from  some  portion 
of  the  tongue.  The  arrangement  of  the  lymphatic  vessels  from  the 
tongue  is  unique  in  that  there  are  so  many  separate  channels  and  dis- 
tinct areas  drained  through  different  sets  of  nodes.  The  vessels  from 
the  anterior  part  of  the  tongue  pass  through  different  sets  of  nodes  than 
do  those  froFQ  the  basal  part.  Eventually,  they  collect  in  the  cervical 
nodes  that  convey  the  lymph  to  a  common  terminal  in  the  veins  on 
either  side.  The  lymph  vessels  from  the  tongue  pass  or  pierce  muscles 
continuously,  and  any  tension  on  these  muscles,  or  any  enlargement  of 
the  salivary  glands,  will  cause  more  or  less  blockage. 

The  tongue  possesses  such  unusually  good  blood  and  lymph  drain- 
age, and  from  the  fact  that  it  is  such  a  movable  organ,  we  find  very  little 
trouble  or  disease,  especially  of  a  malignant  nature.  There  is,  however, 
a  possibility  of  one  or  more  of  the  nerves  becoming  lax  in  their  tone  and 
causing  symptoms  so  well  known  to  all  physicians. 

The  condition  of  the  deep  cervical  lymph  nodes  is  the  most  import- 
ant consideration,  as  the  numerous  lymph  vessels  from  the  tongue  to 
these  deep  centers  are  so  varied  that  blockage  is  not  likely  to  occur  suf- 
ficiently to  prevent  a  marked  checking  in  the  drainage  until  the  deep 
glands  are  reached.  If  they  are  blocked,  there  will  be  a  checking  of  the 
lymph  stream.s  in  the  numerous  vessels  entering  the  deep  nodes. 

Lymphatics  of  the  Thyroid  Region 

In  order  to  understand  clearly  the  drainage  of  the  lymphatic  system 
of  the  neck  and  head,  we  will  begin  with  the  thyroid  gland  and  discuss 
the  lymphatic  drainage  in  this  the  lowest  region. 


Head  and  Neck  35 

The  provelancc  of  goitre  in  certain  districts  has  never  as  yet  been 
clearly  explained.  There  are  many  theories  and  it  does  seem  in  many 
instances  that  drinking  water  has  an  influence  upon  this  gland  in  a  chem- 
ical way.  The  different  kinds  of  goitre  that  are  found  tend  to  compli- 
cate matters,  as  there  has  been  no  explanation,  satisfactorily  given,  as 
yet,  as  to  why  one  person  should  have  exophthalmic  goitre  and  another 
person  a  cystic  goitre.  Anatomically,  we  know  that  the  thyroid  gland 
contains  many  lymphatic  vessels  and  that  the}^  are  often  large  in  size. 
These  lymph  vessels  must  have  drainage  finally  into  the  lymphatic  ducts 
at  the  junction  of  the  jugular  and  subclavian  veins.  The  thyroid  arter- 
ies, the  superior  and  inferior,  supply  the  gland  and  receive  vasomotor 
fibers  from  the  cei-vical  sympathetics.  The  relation  of  the  arteries  to 
the  various  structures  in  the  neck  are  such  that  there  is  usually  little 
interference  from  muscular  tension,  but  there  may  exist  cervical  lesions 
that  cause  undue  disturbance  of  the  innervation  to  the  vessels  in  the 
gland.  We  are  undecided  as  to  the  vasomotor  control,  directly  or  in- 
directly, of  the  honphatic  vessels  and  glands  in  and  aroimd  the  thyi'oid, 
but  we  believe,  from  clinical  evidence,  that  these  lymphatic  vessels  are 
influenced,  indirectly  at  least,  through  the  middle  and  inferior  cervical 
s.\Tnpathetics. 

Cervical  treatment,  including  springing  of  the  vertebrae  that  in- 
fluence the  middle  and  inferior  cervical  sympathetics,  will  oft  times  re- 
duce some  types  of  goitre  without  any  manipulation  directly  over  or 
around  the  thyroid  gland.  This  would  seem  to  indicate  that  while  the 
vasomotors  of  the  thyroid  blood  vessels  are  directly  controlled,  the  lym- 
phatics as  well  are  at  least  indirectly  reached.  It  would  be  quite  im- 
possible to  reduce  an  enlarged  thyroid  gland  by  controlling  the  vascular 
system  only  if  there  existed  huiph  blockage  that  was  causing  a  portion 
of  the  enlargement.  In  goitre  cases  there  is  interference  of  the  drainage 
in  the  right  lymphatic  duct,  as  weU  as  the  thoracic  duct  at  their  points 
of  emptying.  This  may  be  verified  by  the  edema  that  is  so  often  noticed 
above  the  clavicles  and  laterally  to  the  thyroid  gland.  Further  proof  is 
found  in  the  enlarged  cervical  nodes  above  the  gland  through  blockage  or 
lack  of  proper  drainage  of  lymph  into  the  veins. 

The  nodes  located  at  the  termination  of  the  common  carotids  col- 
lect part  of  the  lymph  from  the  thyroid.  There  is  also  a  node  or  two 
anterior  to  the  larynx  just  above  the  thyroid  gland  that  collects  a  i)ortion 
of  the  lymph. 

In  front  of  the  trachea  there  are  a  few  nodes  that  collect  from  down- 
ward coursing  lymph  vessels.  The  recurrent  lan,mgeal  nerve  lies  in  the 
path  of  a  small  number  of  nodes  that  collect  from  the  sides  of  the  thy- 


36 


Lymphatics 


Plate  III.     Lymphatic  drainage  of  the  Thyroid  Gland  and  Larynx;  also 
the  thoracic  duct  receiving  the  lymph  from  the  cervical  nodes. 


Head  and  Neck  37 

roid  gland.  In  certain  cases  of  laryngeal  cough  and  laryngitis  we  have 
found  that  these  nodes  seemed,  when  enlarged,  to  press  and  irritate  the 
nerves,  and  when  reduced,  and  the  lymph  vessels  drained,  the  cough 
subsided.  There  is  no  doubt  in  my  mind  but  what  indurated  or  even 
enlarged  nodes,  not  hardened,  cause  a  great  deal  of  disturbance  to  nerves 
in  the  course  of  these  nodes.  We  will  discuss  later  the  effects  of  the  deep 
cervical  or  internal  jugular  nodes  in  their  relation  to  the  pneumogastric 
nerves  and  brachial  plexus. 

The  deep  cervical  nodes  and  channels  above  the  thyroid  collect 
and  conduct  downward  the  lymph  that  clears  the  vessels  in  the  thyroid 
gland.  In  some  instances  it  would  seem  that  goitre  was  a  lymphatic 
disturbance.  If,  for  any  reason,  the  thoracic  and  right  lymphatic  ducts 
are  blocked  at  their  terminals  there  must  be  a  checking  also  of  the  drain- 
age of  the  Ij'^mph  vessels  in  the  thyroid  gland.  The  lymph  vessels  are 
numerous  in  the  gland  and  their  drainage  course  is  in  two  directions  at 
least,  an  upward,  or  ascending,  and  a  downward  or  descending.  Then 
there  is  the  additional  lateral  drainage.  Disturbed  innervation  to  the 
thyroid  gland  and  blood  vessels  must  have  a  bearing  also  upon  the  lym- 
phatics in  the  thyroid.  This  may  amount  to  a  poisoning  of  the  substance 
of  the  thyroid  that  would  tend  to  increase  its  size.  Draining  of  the 
lymph  vessels  certainly  reduces  the  size  of  the  goitre. 

Treatment 

The  lesion  theory  is  very  applicable  in  this  instance.  Drinking 
water,  nervousness,  or  other  influences,  may  have  caused  the  thyroid  to 
enlarge,  but  in  every  instance  where  goitre  is  present  we  have  found  one 
or  more  osseous  lesions  that  had  a  bearing  upon  the  case.  Usually  there 
are  upper  thoracic  lesions  with  a  corresponding  interference  with  the 
great  vasomotor  centre  at  the  first  and  second  thoracic. 

It  is  at  this  centre  that  the  circulation  of  the  blood  cephalad  is 
controlled.  The  nerve  fibres  pass  through  the  inferior  and  middle  cer- 
vical ganglia  on  their  way  to  the  superior.  As  stated  above,  the  nerve 
supply  of  the  thyroid  may  be  found  in  the  middle  and  inferior  ganglia. 
Thus  we  see  how  the  drainage  of  the  vessels  in  the  thyroid  may  be  in- 
fluenced by  upper  thoracic  lesions.  Venous  stasis  always  interferes  with 
lymphatic  drainage.  Vasomotor  changes  may  indirectly,  through  venous 
stasis  or  edema,  influence  and  retard  lymph  flow.  Indirectly  then,  in 
any  case  of  vascular  irregularity,  the  lymph  stream  is  affected. 

The  upper  costal  attachments  must  be  noted  to  determine  any  costo- 
vertebral subluxation,  and  the  clavicles  must  articulate  properly  if  we 
are  to  expect  free  drainage  in  the  lymph  ducts.     The  venous  drainage 


38  Lymphatics 

of  the  thyroid  temiinates  ahnost  at  the  same  point  as  the  lymph  drain- 
age, and  the  innervation  of  the  thyroid  corresponds  with  the  centres  for 
its  vasomotor  control. 

The  relation  of  the  thyroid  to  the  larj'nx  and  trachea,  including 
the  middle  lobe,  has  a  significance  from  a  lymphatic  standpoint.  The 
nodes  found  in  front  of  the  larynx  and  trachea,  also  the  parathyroid 
glands,  that  surgeons  are  so  careful  not  to  disturb,  are  often  enlarged 
in  laryngeal  troubles  and  this  nodular  enlargement  interferes  with  drain- 
age of  the  ascending  lymph  channels  of  the  thyroid. 

Likewise,  the  blockage  of  the  deep  cervical  chain  of  glands  through 
any  of  the  various  disturbances  found  in  the  head  and  throat  may  in- 
terfere with  the  reduction  of  a  goitrous  condition.  We  see  more  and  more 
the  necessity  of  keeping  the  lymph  flow  cleared  in  any  region  where  there 
is  swelling  or  congestion,  adjacent  or  remote. 

First  of  all,  in  any  instance,  the  terminals  of  the  lymph  tubes  must 
be  kept  free  from  any  interference  or  obstruction;  second,  the  specific 
control  of  the  vasomotors  to  enable  the  calibre  of  the  vessels  to  respond 
to  normal  impulses;  and  third,  the  adjustment  of  all  lesions  to  insure 
normal  tone  and  regulation  of  nerves  and  vessels.  It  is  in  this  same 
region,  that  of  the  middle  and  inferior  cervical  ganglia,  that  we  partially 
influence  heart  action,  and  these  cardiac  nerves  are  often  interfered  with 
by  venous  stasis  and  lymphatic  blockage  through  enlarged  nodules 
and  an  edematous  condition  of  the  tissues.  Tachycardia,  so  pronounced 
in  exophthalmic  goitie,  may  be  influenced  through  a  disordered  lymph 
system.  The  close  relation  of  the  lymph  in  cell  spaces,  or  pericellular 
areas,  may  in  lymph  blockage,  have  an  irritating  effect  upon  the  cardiac 
nerves  from  the  cervical  sympathetics. 

We  will  discuss  later  the  ophthalmic  phase  in  goitre,  and  demon- 
strate the  bearing  the  lymph  nodes  and  vessels  have  in  their  relation  to 
those  in  the  parotid  and  upper  cervical  regions. 

The  blockage  of  the  lymph  in  goitre  cases  has  a  direct  bearing  upon 
the  drainage  of  all  the  lymph  vessels  and  nodes  above  the  thyroid.  This 
explains  the  peculiar  symptoms  noted  in  the  organs  of  the  head,  as  well 
as  in  the  throat,  when  goitre  exists.  The  interference  of  lymph  flow  at 
any  place  between  the  duct  terminals  and  a  remote  area  invariably 
means  a  series  of  lymph  disturbances  at  the  points  beyond  the  blockage. 

\\'e  have  tried  thus  far  to  show  the  advantage  of  considering  the 
thyroid  region  as  a  .strategic  point  in  the  drainage  plan  of  thelymphatc 
vessels  in  relation  to  points  above.  We  will  now  take  up  the  region  of 
the  larynx  and  show  how  necessary  free  drainage  of  this  area  is,  to  clear 
the  lymph  vessels  and  nodes  above. 


Head  and  Neck  39 

Lymphatics  of  the  Larynx  and  Trachea 

As  stated  on  the  precedins:  page,  the  drainage  of  all  nodes  and  vessels 
above  must  necessarily  pass  by  the  region  of  the  thyroid  to  drain  into 
the  subclavian  vein.  The  freedom  of  blockage  to  the  lymphatic  vessels 
in  the  larynx  will  depend  on  the  free  flow  of  lymph  below  this  region. 
As  in  the  thyroid  body,  there  are  two  sets  of  laryngeal  lymph  vessels, 
the  superior  and  inferior.  Their  drainage  course,  after  passing  through 
the  thyrohyoid  and  cricothyroid  membranes,  is  outward  and  downward 
toward  the  deep  cervical  glands.  The  inferior  sometimes  terminates 
in  the  node  lying  in  front  of  the  cricothyroid  membrane,  or  in  nodes  in 
front  of  the  trachea  in  relation  to  the  inferior  thyroid  artery. 

These  nodes,  sometimes  referred  to  as  the  anterior  cervical  nodes, 
lie  in  front  of  the  larynx  and  trachea,  near  the  anterior  jugular  vein. 
The  deeper  set  drain  the  lower  portion  of  the  larynx  and  the  upper  part 
of  the  trachea.  This  last  set  also  drain  the  upper  part  of  the  thyroid 
gland  as  alieady  pointed  out.  The  main  collecting  nodes  for  the 
lymph  of  the  laryngeal  region  are  located  at  the  bifurcation  of  the  com- 
mon carotid  and  on  the  inferior  thyroid  artery.  These  deep  cervical 
nodes  lie  in  the  course  of  the  terminal  drainage  of  the  lymph  stream  from 
the  head  and  neck. 

Some  of  the  lymph  vessels  follow  the  superior  laryngeal  artery. 
The  larynx  with  its  vocal  cords  is  controlled  and  innervated  by  the 
superior  and  inferior  laryngeal  nerves.  The  sympathetic  nerve  fila- 
ments follow  the  laryngeal  nerves.  Control  of  the  cords  and  action  of 
the  various  muscles  attached  to  the  vocal  box  are  dependent  upon  nor- 
mal nerve  impulses.  The  vascular  supply  is  controlled  through  the 
sympathetics.  The  venous  and  lymph  drainage  insures  a  clearance  of 
these  various  muscles  and  tissues. 

Treatment 

The  tone  of  the  nerves  depends  upon  the  freedom  from  pressure  or 
irritation  at  any  point  along  their  course.  If  cervical  lesions  exist,  caus- 
ing muscle  contraction  or  stress  upon  nerves  and  tissues,  the  tone  of 
the  lar\'ngeal  muscles  will  be  lowered.  If  there  is  vasomotor  interference 
in  an}'  way,  there  will  be  corresponding  irregularity  in  the  supply  and 
drainage  in  the  larynx. 

Vascular  insufficiency  will  mean  lymphatic  disturbance  and  a  checked 
flow  of  lymph.  Congestion  of  the  laryngeal  membranes  or  tension  of 
the  laryngeal  muscles  affects  the  lymph  flow  and  this  condition  will  re- 
main until  normal  tone  is  re-established  through  the  correction  of  lesions 
and  the  relaxation  of  the  nmscles  under  the  jaw  in  the  region  of  the  hy- 


40 


Lymphatics 


Pi.ATK  I\'.     Crncml  scheme  of  honph  drainage  of  head  and  thyroid  regions. 


Head  and  Neck  41 

oid.  Blockage  of  the  lymph  stream  at  a  lower  point  in  the  lymph  vessels 
or  nodes,  will  cause  interference  in  the  laryngeal  region.  This  will  ex- 
plain  why  we  considered  the  thyroid  gland  region  first.  There  must 
be  an  outlet  for  the  lymph  in  order  that  the  laryngeal  region  may  clear 
itself. 

Each  nerve  and  vessel  going  to  the  larynx  must  be  insured  normal 
freedom.  Any  lesion  that  will  interfere  with  the  laryngeal  nerves  will 
cause  disturbance  according  to  the  functions  of  that  nerve.  The  re- 
current laryngeals,  with  their  peculiar  loopings,  may  be  interfered  with 
by  nodular  enlargements  or  thyroid  swelling,  or  lesions  that  have  tensed 
the  nmscles  over  the  course  of  the  nerves.  The  vasomotors  that  regu- 
late the  laryngeal  arteries  indirectly,  if  not  directly,  regulate  the  lymph 
vessels,  either  at  the  drainage  points  in  the  larynx  or  in  the  larger  vessels 
that  receive  and  carry  onward  the  flow  of  lymph.  Here,  again,  we  un- 
derstand the  cardinal  point  in  every  disease,  namely,  due  consideration 
of  the  drainage  at  every  point  between  the  affected  part  and  the  termina- 
tion of  the  stream. 

The  deep  cervical  lymph  nodes  collect  eventually  the  lymph  of 
the  head  and  neck,  and  it  is  well  to  trace  the  nodes  as  nearly  as  possible 
and  see  that  there  is  no  undue  enlargement  or  blockage  of  lymph.  There 
are  many  lesions  that  may  cause  nodular  enlargement,  outside  of  toxins 
which  overtax  the  nodes. 

We  will  consider  next  the  lymph  drainage  of  the  tonsils.  We  do 
this  before  discussing  the  drainage  of  the  gums  because  we  want  to  em- 
phasize certain  glands  and  nodes  that  have  a  bearing  upon  the  lymph 
vessels. 

The  drainage  of  the  upper  part  of  the  trachea  is  often  different  in 
its  termination  than  the  lower  part.  The  upper  part  is  drained  in  com- 
mon with  the  thyroid  gland  region,  while  the  lower  trachea  is  drained 
in  common  through  the  tracheo -bronchial  nodes  which  eventually  unite 
with  the  broncho-mediastinal  trunk  that  may  empty  at  a  different  point 
in  the  subclavian  vein  than  does  the  right  lymphatic  duct,  or  even  the 
thoracic  duct.  There  may  be  a  blockage  of  the  upper  tracheal  nodes 
and  yet  the  lower  tracheal  nodes  may  have  a  free  lymph  flow  into  the 
vein. 

Lymphatics  of  The  Tonsils 

Under  this  heading  we  wish  to  discuss  the  general  lymphatic  drain- 
age  of  the  naso-pharyngeal  region.  This  general  discussion  will  include 
the  various  lymph  glands  and  adenoid  tissues.  We  will  leave  the  ap- 
plied anatomy  of  the  eye,  ear,  nose  and  throat  to  those  who  have  written 
upon  that  subject.     Our  intention  is  to  call  the  student's  attention  to 


42  Lymphatics 

the  drainage,  in  a  general  way,  of  an  area  so  closely  studded  with  lym- 
phoid tissue. 

It  will  be  necessary  to  include  drainage  points  and  receiving  nodes 
that  exist  in  the  region  of  the  mandible.  In  this  general  drainage  we  will 
note  the  possibility  of  interference  in  several  places  where  muscles  may, 
through  undue  tension,  block  the  lymph  flow.  We  will  also  refer  to  the 
location  of  the  salivary  glands  and  show  that  the  effect  of  enlargement 
may  interfere  with  the  drainage  of  the  lymph  flowing  from  points  above. 

If  all  of  the  lymph  vessels  and  nodes  of  the  tonsillar  region  could 
be  shown  along  with  all  receiving  and  collecting  nodes,  also  efferent  lymph 
vessels,  we  would  observe  that  rings  within  rings  of  lymph  vessels,  in- 
cluding nodes,  would  complete  the  circles.  One  circle  would  not  in- 
clude these  vessels  and  nodes,  as  described  by  some  authors.  Three  or 
more  distinct  rings  may  be  noticed. 

The  first  would  include  the  palatine  tonsils,  the  lingual  nodes,  and 
lymph  vessels.  Outside  of  this  ring  a  second  would  include  the  pharyn- 
geal tonsil,  the  Eustachian  tonsils,  retropharyngeal  glands,  styloid,  and 
lateral  pharyngeal  glands. 

The  third  ring  would  include  the  nodes  found  on  the  sternohyoid 
muscle  and  at  the  termination  of  the  common  carotid  artery;  also  a 
node  or  two  on  sternomastoid.  In  front  under  the  mandible,  the  sub- 
maxillary and  submental  nodes,  and  finally  the  hyoid  nodes. 

These  three  circles  will  make  clear  the  lymphatic  drainage  of  a 
region  so  rich  in  lymphoid  tissue. 

First,  we  will  show  the  drainage  of  the  inner  ring.  The  tonsils 
are  drained  by  lymph  vessels  that  pierce  the  walls  of  the  pharynx  on 
their  lateral  surfaces  and  end  in  glands  by  the  walls  of  the  internal  jugu- 
lar veins. 

The  arches,  adjacent  to  the  palatine  tonsils,  are  also  drained  by 
these  vessels.  The  nodes  receiving  drainage  of  the  tonsils  and  arches 
lie  on  the  jugular  vein  near  the  lower  border  of  the  digastric  muscle. 
Free  drainage  of  lymph  in  the  region  of  the  tonsils  and  the  glosso-palatine 
and  pharyngo-palatine  arches  may  be  blocked  by  traction  of  the  muscles 
in  this  region.  The  nerves  supplying  the  muscles  may,  through  lesions, 
be  contractured,  or  congestion  of  adjacent  parts  may  cause  undue  stress 
upon  the  tissues.  The  digastric  muscle  may  have  disturbed  innervation 
and  cause  the  nuiscle  to  draw  upon  the  lymph  vessels  leading  to  the  nodes 
on  the  jugular  vein.  The  styloglossus  also,  if  contracted,  may  inter- 
fere with  drainage  of  lymph  from  the  tonsillar  area. 

The  vascular  arrangement  of  the  tonsils  is  unusual,  as  foin*  arteries 
at  least  supj)ly  each  gland.  However,  all  of  these  arteries  are  branches 
of  one  main  artery,  the  external  carotid. 


Head  and  Neck  43 

It  is  the  venous  and  lymph  drainage  of  the  tonsils  that  interests  us 
most.  If  the  veins  are  compressed  through  congestion,  scar  tissue,  or 
muscle  contraction  over  or  around  them,  we  are  more  apt  to  find  a  re- 
tarded flow  of  lymph.  Enlarged  nodes  at  a  lower  point  will  back  up 
the  lymph  and  cause  a  disturbance  in  the  tonsils  and  adjacent  tissues. 
Again  we  see  the  need  of  a  clear  lymphatic  drainage  all  the  way  down 
to  the  terminals  in  the  subclavian  veins. 

In  tonsillitis  the  lymph  nodes  enlarge  almost  immediately  and  can 
be  palpated  readily  near  the  angle  of  the  mandible.  If  unduly  blocked 
for  a  period  of  time,  other  nodes  enlarge  and  there  is  a  general  edematous 
condition  of  the  tissues  under  the  ramus.  It  does  not  take  long  to  block 
lymph  nodes  and  vessels  and  unless  they  are  cleared  the  nodes  in  ad- 
jacent regions  show  enlargement.  First  of  all,  in  tonsillar  infection,  we 
must  start  at  the  supraclavicular  area  and  establish  free  lymph  flow, 
then  work  to  clear  the  nodes  above  that  point.  Every  muscle  should 
be  relaxed  through  the  points  of  innervation.  That  is,  the  correction 
of  lesions  that  will  allow  free  impulses  to  the  muscles.  The  lymph  stream 
is  readily  checked  in  many  ways.  The  lymph  vessels  are  pliable  and 
readily  compressible. 

Indurated  nodes  are  often  found  that  have  been  blocked  so  long 
through  lack  of  treatment  that  would  have  cleared  them  when  they  were 
pliable.  Often  enlarged  nodes  in  children  following  colds  or  some  in- 
fectious disease  are  allowed  to  remain  congested  and  finally  become  in- 
durated. In  these  cases,  the  lymph  must  follow  other  vessels  that  par- 
tially lessen  the  load. 

It  is  well  to  watch  the  nodes  in  children  and  re-establish  good  lymph 
drainage.  This  may  save  secondary'  infection  at  a  later  date.  It  is 
comparatively  easy  to  regulate  the  lymph  stream  in  a  child  if  taken 
when  the  vessels  and  nodes  are  first  blocked. 

The  most  common  source  of  bronchial  and  lung  infection  is  through 
the  throat ;  very  seldom  do  we  find  a  tubercular  condition  that  has  started 
from  any  source  but  by  way  of  the  throat.  The  blockage  of  the  cervical 
lymphatic  glands  will  cause  enlargement  of  the  broncliial  glands  and 
th(Mi  it  is  but  a  simple  matter  for  the  nodes  at  the  roots  of  the  lungs  to 
become  involved.  Infection  passes  downward  readily,  unless  the  lymph 
vessels  and  nodes  are  cleared  and  properly  drained,  into  the  lymph 
ducts  and  then  the  subclavian  veins.  The  lingual  drainage  has  been  dis- 
cussed earlier  in  this  chapter. 

We  thus  see  that  the  inner  circle  collects  the  lymph  and  passes  it 
through  nodes  that  are  connected  with  the  cervical  chain. 

The  second  ring  includes  a  greater  area.  The  retropharj-ngeal 
nodes  arc  separated  from  the  atlas  by  the  major  rectus  capitis  muscle. 


44 


Lymphatics 


Plate  V. 
Lymphatic  drainage  vessels  from   the  naso- 
pharjTigeal  and  tonsillar  regions. 


Head  and  Neck  45 

This  is  just  back  of  the  upper  portion  of  the  phaiynx.  The  nodes 
through  their  efferents  drain  into  the  cervical  nodes  that  He  near  the  main 
vessels  of  the  neck. 

We  have  mentioned  the  retropharyngeal  nodes  first  in  this  second 
ring  because  the  collecting  lymph  vessels  are  numerous,  and  include 
several  lymph  areas,  as  the  Eustachian  nodes,  and  nasopharyngeal  region, 
and  the  fossae  of  the  nose.  Before  the  lymph  reaches  the  deep  cervical 
nodes  a  number  of  the  channels  pass  through  the  subparotid  nodes. 
The  soft  palate  is  also  drained  through  the  retropharyngeal  nodes.  The 
drainage  of  this  second  ring  may  be  interfered  with  in  several  ways. 
The  location  of  the  retropharyngeal  nodes  is  such  that  faulty  innerva- 
tion of  the  rectus  muscle  may  disturb  the  free  lymph  flow.  An  atlas 
lesion  maj^  alter  the  drainage  directly  or  through  a  disturbance  of  the 
tissues  from  stress  or  through  tissue  congestion.  These  nodes  are  very 
important  lymph  structures  and  lie  in  a  position  that  makes  possible 
their  enlargement  or  induration  through  various  lesions  of  the  cervical 
vertebrae,  or  hyoid  lesions  that  cause  traction  upon  the  muscles  or  laryn- 
geal and  tracheal  areas.  Vasomotor  disturbances  to  these  parts  may 
cause  an  alteration  in  the  tissues  covering  the  nodes.  The  subparotid 
nodes  that  receive  part  of  the  drainage  may  be  disturbed  through  pressure 
of  an  enlarged  parotid. 

The  receiving  cervical  nodes  may  already  be  overburdened  with 
lymph  and  a  backing  up  of  the  lymph  stream  may  result  in  enlargement 
of  the  retropharyngeal  nodes  and  a  tissue  congestion  or  even  hyper- 
plasia result.  Cervical  muscular  contraction,  through  colds,  may  pro- 
duce venous  stasis  and  cause  a  general  blockage  in  the  lymph  channels. 

Lower  cervical  lesions  and  even  upper  thoracic  may  interfere  with 
drainage  at  the  terminals  which  will  be  reflected  in  the  pharyngeal  tis- 
sues. 

The  third  ring  and  outer  one,  while  more  superficial,  has  a  signifi- 
cance in  that  a  vast  area  is  drained. 

The  nodes  on  the  sternohyoid  muscle  are  connected  with  those  of 
the  cervical  group  chain,  also  those  found  on  the  sternomastoid.  This 
ring  includes  the  submental,  submaxillary  and  hyoid  region  nodes  al- 
ready referred  to.  The  many  lesions  that  may  cause  interference  with 
these  nodes  are  readily  understood  when  we  notice  the  areas  drained  by 
these  lymph  tissues  and  vessels. 

A  subluxated  hyoid  may  cause  considerable  traction  and,  on  careful 
palpation,  the  nodes  on  one  side  may  be  found  to  be  enlarged.  The 
deep  cervical  may  block  the  more  superficial  nodes.  The  mastoid  and 
occipital  nodes  may  be  enlarged  through  the  lower  interference.     It  is 


46 


Lymphatics 


Plate  VI. 

lAinphatics  of  the  mastoid,  occipital  and 

cervical  regions. 


Head  and  Neck  47 

well  to  go  over  all  the  nodes  palpable,  and  try  and  determine  the  rela- 
tion between  the  enlarged  nodes  and  the  congested  areas  found  upon 
examination  of  the  nose  and  throat. 

The  nodes  in  the  three  rings  are  bound  to  be  enlarged  more  or  less 
when  there  is  pharyngitis,  tonsillitis,  or  Eustachian  closure.  The  nodes 
will  not  reduce  in  size  to  any  appreciable  extent  until  tissue  congestion 
is  relieved. 

We  have  outlined  in  a  general  way  tlie  main  nodes  in  these  regions. 
The  chapters  by  specialists  on  eye,  ear,  nose,  and  throat  will  include 
more  detailed  statements. 

The  main  point  we  have  tried  to  emphasize  in  the  lymph  drainage 
of  the  head  is  the  attention  that  must  be  paid  to  the  terminals  of  the 
duets  that  empty  into  the  subclavian  veins.  In  many  cases  the  fullness 
of  the  tissues  above  the  clavicles  will  be  noticed,  and  that  the  left  supra- 
clavicular area  is  more  likely  to  become  edematous  than  the  right.  This 
fullness  must  be  reduced  before  we  can  expect  to  drain  the  head  lymph 
vessels.  Stasis  in  the  veins  will  only  aggravate  the  lymph  vessels  and 
cause  additional  blockage  in  their  channels.  Vasomotor  control  of  all 
vessels  in  the  neck  and  throat  will,  when  regulated,  make  lymph  flow 
more  normal.  Indurated  nodes  may  block  the  lymph  stream  until 
collateral  circulation  is  established. 

It  is  unwise  to  work  directly  over  enlarged  lymph  nodes.  It  is  far 
better  to  regulate  the  blood  vessel  flow  and  work  to  the  end  of  freeing 
the  lymph  stream  through  reducing  the  general  tissue  congestion. 

Lymphatics  of  the  Teeth  and  Gums 

In  discussing  this  section  of  the  head  we  might  say  that  texts  at- 
tach too  little  significance  to  the  lymph  vessels  found  in  the  alveolar 
region.  Histologists  are  prone  to  pass  by  the  subject  of  lymph  vessels 
in  connection  with  the  teeth  and  gums,  and  dental  anatomists  are  equally 
reticent.  Bailey  gives  credit  for  Schweitzer's  statement  that  ''an  arbori- 
zation of  small  lymph  vessels  in  the  pulp  of  the  croWn,  converging  to  a 
few  larger  lymph  vessels  in  the  root  pulp  and  accompanying  the  blood 
vessels  through  the  foramina  of  the  apex"  is  observed  in  histological  find- 
ings. 

Lymph  channels  in  the  pulp  are  minute  but  they  have  a  bearing 
upon  the  drainage  system  that  insures,  when  cleared,  normal  tissue.  We 
are  inclined  to  believe  that  wherever  there  are  arterioles  and  capillaries, 
there  are  corresponding  lymph  spaces  and  capillaries,  and  that  wherever 
there  are  capillary  veins,  there  are  lymph  drainage  spaces  or  channels. 
The  lymphatic  drainage  system  is  so  complete  in  the  various  organs 


48  Lymphatics 

and  tissues  of  the  body  that  we  have  come  to  depend  upon  our  treat- 
ment of  this  system  to  clear  any  possible  congested  or  disturbed  tissue 
condition.  The  pulp  of  a  tooth  is  the  life  of  it,  and  drainage  is  always 
equally  important  to  supply.  The  gums  are  well  supplied  by  plexuses 
of  capillaries. 

On  the  inner  surface  of  the  gums  from  the  mucous  membrane  the 
collecting  ducts  have  their  beginning.  From  this  point  they  pass  be- 
tween the  teeth  to  a  duct  that  collects  the  lymph.  The  arrangement  is 
of  a  semicircular  plan  and  lies  on  the  outer  surface. 

The  submental  nodes  receive  the  lymph  from  the  front  lower  gums. 
The  submaxillary  nodes  collect  from  the  back  gums  both  upper  and 
lower.  The  buccinator  nodes  sometimes  collect  a  part  of  the  lymph; 
also  the  superior  deep  cervical  glands.  The  lymph  vessels  of  the  teeth 
follow  practicallj^  the  same  course.  The  upper  deep  cervical  nodes 
eventually  collect  the  lymph. 

The  blockage  of  lymph  in  the  gums  and  possibly  in  the  pulp  marks 
the  beginning  of  abscesses  and  pyorrhoea.  Perfect  blood  supply  and 
venous  and  lymph  drainage  will  prevent  decay,  providing  tartar  is  kept 
cleared  and  food  particles  removed  from  between  the  teeth. 

The  gums  in  order  to  have  tone  and  remain  pinkish  in  color  must 
have  proper  blood  supply  and  free  drainage.  Systemic  disorders  and 
anemic  conditions  afifect  the  teeth  and  we  can  hardly  expect  to  establish 
a  local  tone  when  a  systemic  absence  of  tone  exists.  Much  can  be  done, 
however,  in  keeping  the  gums  healthy  if  we  watch  the  lymph  drainage. 
The  blocking  of  the  submental  or  submaxillary  nodes  will  shortly  cause 
a  disturbance  in  the  gums.  Any  lesion  that  will  contract  the  hyoid 
muscles  or  larj^ngeal  tissues  may  interfere  with  the  lymph  flow  from  the 
gums. 

The  vasomotors  to  the  blood  vessels  supplying  the  teeth  and  gums 
may  be  affected  by  cervical  lesions.  The  veins  and  lymph  vessels  will 
be  affected  by  muscle  contraction  causing  blockage  of  nodes  in  the  deep 
cervical  group  of  glands.  The  presence  of  goitre  may  affect  the  gums 
and  teeth  through  a  checking  of  the  venous  and  lymph  vessel  flow. 

Subluxations  of  the  mandible  or  hyoid  will  cause,  in  some  instances, 
enlargement  of  the  salivary  glands  and  block  lymph  flow.  The  muscles 
attached  to  the  mandible  are  often  contracted  through  lesions  and  this 
will  interfere  with  drainage. 

In  order  to  have  perfect  circulation  in  the  teeth  and  gums,  we  must 
not  only  keep  them  cleansed,  but  see  that  no  interference  with  the  sup- 
ply and  drainage  exists.  Too  little  stress  has  been  laid  upon  the  lymph 
drainage  of  the  gums  and  teeth. 


Head  and  Neck 


49 


Plate  VII.  Nodes  in  Relation  to  Salivary  Glands. — (1)  Parotid  gland. 
(2)  Tongue.  (3)  Submaxillary  gland  and  Ij-mph  node.  (4)  Sub- 
lingual gland  and  nodes  adjacent.  (5)  Carotid  artery.  (6)  Internal 
jugular.  (7)  Thoracic  duct.  (8)  Node  receiving  Ij-mph  from  the 
tongue  and  parotid  region.  (9)  Deep  cervical  nodes.  (10)  Submental 
node.     (11)  Lymph  drainage  from  gums. 


50  Lymphatics 

The  presence  of  enlarged  nodes  in  the  submental  and  submaxillary 
gland  region  will  always  indicate  a  blockage  in  the  lymph  vessels  that 
should  clear  the  alveolar  areas.  We  have  shown  in  discussing  the 
tongue  the  necessity  of  considering  the  drainage  of  that  organ  in  order  to 
have  a  free  drainage  for  the  teeth  and  gums.  The  lymph  vessels  follow 
a  course  quite  parallel  in  many  respects  to  those  from  the  alveolar  region. 
The  blockage  of  lymph  vessels  and  nodes  in  one  instance  will  affect  the 
flow  in  the  other. 

Pyorrhea 
Lymphatically  Considered 

Until  recently  we  suspected  unbrushed  teeth  to  be  a  factor  in  the 
cause  of  pyorrhea.  Food  particles  remaining  between  the  teeth  were 
supposed  to  cause,  or  set  up,  a  fermentation  that  resulted  in  pyorrhea. 
On  second  thought  we  have  changed  our  minds,  because  the  very  people 
who  do  not  take  particular  pains  with  cleansing  their  teeth  oftimes  have 
good  teeth.  Before  tooth  brushes  were  a  common  toilet  article,  pyorrhea 
was  not  known  to  exist  in  the  same  degree  as  at  the  present  time. 

Now-a-days  pyorrhea  starts  with  some  people  by  the  time  they  are 
in  their  twenties,  and  sometimes  earlier,  and  at  forty  dentists  find  it 
uncommon  not  to  detect  some  degree  of  this  trouble. 

We  have  labored  long  to  find  the  cause  of  pyorrhea,  and  have  re- 
cently satisfied  ourselves  that  the  cause  is  clear  to  those  who  will  go  into 
the  subject  thoroughly. 

It  is  not  a  germ  disease ;  decidedly,  no.  It  is  not  necessarily  a  result 
of  unbrushed  teeth  conditions,  but  it  is  a  result  of  an  acrid  formation  be- 
ginning at  the  extreme  root  ends  of  the  teeth  in  the  way  of  tiny  abscesses 
with  a  granular  pus  collection.  These  small  abscesses  are  beyond  the 
reach  of  the  probe,  and  the  root  canal  leading  to  a  closed  cavity  in  the 
crown  of  the  teeth  prevents  this  acrid  pus-like  formation  from  passing  up 
into  the  pulp  in  any  appreciable  quantity.  Instead  of  following  the 
vessels  into  the  pulp,  the  acrid  accumulation  gradually  works  its  way  up 
between  the  gums  and  the  roots  of  the  teeth  and  loosens  the  gums  from 
the  teeth.  This  acrid  fluid  substance  affects  the  gums  to  the  extent  of 
causing  them  to  recede  and  the  peculiar  odor  and  color  of  the  gums  verify 
the  statement  that  the  pyorrhea  collection  of  acrid  pus  is  destroying  the 
gums  and  causing  an  alveolar  disturbance  that  leads  to  but  one  thing: 
extraction. 

Now,  wo  will  go  back  to  the  primaiy  cause  of  pyorrhea  and  lead  up 
to  the  accunmlation  referred  to  above.  The  beginning  is  a  combina- 
tion of  liver  and  kidney  trouble,  and  back  of  this  disturbed  organic  con- 


Head  and  Neck  51 

dition  is  a  faulty  circulation  and  innervation  of  these  organs.     The 
chemical  changes  in  the  lymph  stream  and  nodes  due  to  altered  function 
of  the  liver  and  kidneys  reflect  themselves  in  time  upon  the  salivary 
glands  and  adjacent  lymph  nodes.     It  resembles  a  mild  uraemic  poison- 
ing.     The  altered  salivary  secretion,  the  lymph  node  enlargement  and 
changed  lymph  substance,  both  combine  to  produce  in  the  vessels  and 
lymph  spaces  around  and  to  the  teeth,  a  substance  acrid    in  nature. 
Through  liver  and  kidney  alterations  in  function  and  secretions,  a  de- 
posit of  toxic  products  cause.:^  destruction  of  tissue  at  the  extreme  points 
of  the  teeth  roots  resulting  in  tiny  abscesses.     This  may  be  unlike  an 
alveolar  abscess  in  that  the  changed  lymph  substance  combined  with 
the  salivary  gland  secretion  may  be  more  acrid  and  of  a  more  destructive 
nature.     When  this  acrid  pus  formation  starts  to  eat  its  way  toward  the 
free  gum  surface  there  is  an  odor  given  off  which  is  not  hard  to  recognize. 
The  lymph  vessels  between  the  teeth  convey  this  eating  fluid  to  adjacent 
teeth  roots  and  soon  three  or  more  roots  are  involved.     There  are  cer- 
tain fluids  the  specialists  use  to  counteract  this  pyorrhea  condition,  but 
it  is  diflScult  to  reach  because  the  tip  end  of  the  roots  contain  the  first 
trace    of    acrid  pus.     The    lymph    nodes    in  any  case  of  pyorrhea  are 
invariably  affected.     The  poisons  are  retained  and  tissues  are  being 
eaten  away.     The  salivary  glands  no  longer  secrete  a  normal  substance, 
as  there  is  lymph  blockage  and  accumulated  poisons  in  the  way  of  toxic 
products  from  a  systemic  disturbance  caused  by  an    altered  organic 
change  in  the  liver  and  kidneys. 

Thus  we  find  the  cure  of  pyorrhea  is  one  of  prevention.  The  liver 
must  be  kept  functioning  normally  and  the  kidneys  performing  a  normal 
secretion  of  fluid.  Lesions  that  cause  a  lack  of  regularity  in  the  blood 
supply  to  the  kidneys  and  liver,  or  lesions  that  cause  lack  of  nerve  tone 
or  vasomotor  control  will  be  the  primary  cause  of  pyorrhea. 

We  are  living  in  a  diff"erent  age  and  xmder  different  circumstances 
than  did  the  people  of  a  generation  or  two  ago.  We  have  "nerves"  now- 
a-days,  and  we  have  changed  secretions  in  the  various  organs.  The 
influenza  epidemic  is  an  example  of  what  excitement  and  peculiar  weather 
conditions  may  bring  upon  a  people  who  live  constantly  on  high  tension. 
No  organ  can  function  normally  when  the  mind  is  constantly  agi- 
tated, and  excitement  prevails.  The  cause  of  an  increase  in  pyorrhea 
is  due  then  not  only  to  lesions  of  aft  osseous  nature,  but  lesions  of  a  mental 
nature  as  well.  We  consume  in  our  nervous  state  chocolates  and  finely 
ground  food  stuffs,  and  we  wonder  why  our  teeth  go  bad.  We  go  along 
with  a  slight  blood  pressure  or  a  mild  nephritis  and  still  expect  that  a 
systemic  disturbance  will  not  reflect  itself  upon  some  weakened  tissue. 


52  Lymphatics 

Changed  chemistry  in  the  lymph  vessels  and  nodes  along  with  altered 
secretions  of  the  glands  in  various  regions  will  result  in  pyorrhea  as  well 
as  weak  eyes,  and  general  symptoms  that  are  always  associated  with 
these  altered  states  of  the  body  mechanism. 

In  this  connection  we  might  add  that  the  gastric  disorders  found 
in  connection  with  the  diseased  teeth  is  but  a  secondary  poisoning  through 
salivary  secretions  being  carried  downward  from  the  mouth  in  swallow- 
ing.  If  the  pyorrhea  is  advanced,  the  additional  exudate  from  between 
the  gums  and  roots  of  teeth  will  mix  with  the  salivary  secretion,  and 
result  in  gastric  disorders. 

We  never  find  pyorrhea  affecting  the  teeth  and  gums  alone.  There 
is  always  an  additional  poisoning  of  the  various  weakened  areas  of  the 
body  by  the  lymph  stream  that  is  overladen  with  toxic  substances  from 
deranged  organs. 

In  some  cases  the  whole  system  is  affected;  joints,  muscles,  and 
various  tissues. 

The  peculiar  localization  of  pus  at  the  roots  of  the  teeth  is  due  to 
the  combination  of  lymph  and  salivary  fluid  concentrating  upon  a  fairly 
closed  cavity  that  is  more  or  less  liable  to  the  collection  of  saliva  and  to 
tartar  formations.  There  is  no  other  proposition  in  the  human  body 
quite  like  that  of  the  alveolar  sockets.  The  peculiar  pressure  upon  the 
teeth  in  trituration  and  in  nervous  troubles  where  there  is  a  ''grinding  of 
the  teeth, "  make  the  sockets  containing  the  roots  of  the  teeth  liable  to 
irritation  if  there  is  not  a  normal  lymph  and  blood  supply.  As  soon  as 
there  is  an  alteration  in  the  blood  or  lymph  the  tendency  of  the  gum  to 
cleave  is  made  manifest,  and  then  the  combined  altered  saliva,  along 
with  food  particles,  and  the  altered  lymph  make  the  changes  that  produce 
the  tiny  abscesses,  and  the  eating  away  of  the  gums  that  eventually  re- 
cede. It  is  an  acfid  proposition  resulting  from  an  altered  lymph 
flow  that  has  concentrated  upon  these  all-but-hidden  sockets  or  pockets. 


CHAPTER  THREE 

APPLIED  ANATOMY  OF  LYMPHATICS  OF  THE 
HEAD  AND  NECK 

IN   RELATION   TO  ACUTE  POLIOMYELITIS 

We  have  already  mentioned  that  the  most  direct  area  of  infection 
in  infantile  paralysis  is  through  the  membranes  of  the  nose  and  throat. 
The  virus  gains  entrance  during  respiration  and  deglutition. 

We  have  also  referred  to  the  mode  of  infection  through  the  alimen- 
tary tract.  The  virus  is  carried  along  with  the  bolus  of  food  and  enters 
the  stomach.  During  the  process  of  digestion  it  is  conveyed  to  the  in- 
testinal tract  and  the  system  takes  up  the  virus  and  its  poisons  by  way 
of  the  lacteals  and  blood  channels. 

A  more  direct  infection  of  the  central  nervous  system  may  take 
place  through  the  lymphatics  of  the  head  and  neck.  The  membranes  of 
the  nose,  nasopharyngeal  region  and  mouth  are  rich  in  lymphoid  tissue. 
The  close  connection  between  the  lymphatic  tissues  of  these  areas  and 
those  found  in  the  head  and  neck  allow  a  conveyance  of  the  virus  to  the 
membranes  of  the  brain  and  spinal  cord.  The  openings  for  communica- 
tion are  numerous  and  the  paths  for  the  conveyance  of  infection  are 
closely  connected.  The  superficial  and  deep  lymphatic  vessels  and 
nodes  found  in  the  neck  and  throat  allow  of  ready  communication  and 
transmission  of  the  micro-organisms  and  their  toxic  products.  The 
central  nervous  system  may  be  almost  directly  invaded  by  the  virus 
found  in  the  membranes  and  lymphatics  of  the  nasopharyngeal  region. 
Once  the  virus  reaches  membranes  protecting  the  central  nervous  system 
the  upward  invasion  to  the  brain  from  the  cervical  region  is  readily 
accomplished. 

The  cercbro -spinal  fluid  surrounding  the  cord  also  supplies  the 
area  around  the  brain.  There  is  a  communication  between  the  cord  and 
brain,  as  the  same  coverings  that  surround  the  cord  are  continuous  with 
those  covering  the  brain. 

One  of  the  most  noticeable  symptoms  in  an  acute  case  of  infantile 
paralysis  is  headache.  There  is  also  pain  in  the  neck.  The  temperature 
increases  in  a  typical  case  until  it  reaches  103°  or  more.  The  congestion 
in  the  head  and  neck  is  marked.  The  neck  seems  swollen;  the  lymph 
nodes  are  enlarged  and  indurated.  The  lymphatics  are  involved  as 
well  as  the  blood  vessels.  The  lymphatics  have  carried  the  virus  to  the 
hidden  membranes  of  the  central  nervous  system. 

—53— 


54 


Lymphatics 


Plate  VIII,    Vascularization  of  the  central  nervous  system  from  which 
the  lymph  spaces  receive  their  supply. 


Acute  Poliomyelitis  55 

The  invasion  may  have  taken  the  route  found  in  the  cervical  region, 
the  cephahc  membranes  first  becoming  infected.  The  virus  in  this 
case  must  needs  travel  downward  in  the  central  nervous  system  if  the 
case  is  one  that  is  not  abortive  in  type.  General  infection  of  the  cord 
may  or  may  not  take  place.  The  cephalic  membrane  involvement 
may  be  sufficient  to  cause  a  bulbar  paralysis  which  will  eventually  affect 
all  points  below  and  prove  fatal  in  nature  if  sufficient  destruction  takes 
place.  x4gain,  it  is  the  amount  of  resistance  the  tissues  have  that  will 
determine  the  extent  of  the  destruction  in  the  nerve  cells.  The  lym- 
phatic engorgement  will  depend  upon  the  lack  of  freedom  of  circulation 
and  the  quality  of  the  blood  and  lymph. 

The  nodules  will  indurate  in  proportion  to  the  amount  of  blockage. 
The  more  regular  the  circulation  the  better  the  oxygenation  of  the  blood 
will  be,  and  good  blood,  well  aerated,  is  the  best  of  germicides.  The 
microorganisms  lose  their  power  in  proportion  to  the  vitality  of  the 
tissues  they  have  to  work  in. 

The  extreme  amount  of  congestion  in  the  head  and  neck  is  due  in 
part  not  to  the  virulence  of  the  virus  as  much  as  to  the  amount  of  ob- 
struction found  in  relation  to  the  blood  vessels  and  lymph  channels. 

The  nodal  induration  is  much  more  rapid  when  the  blood  circula- 
tion is  impeded.  The  feverish  condition  of  the  head  and  the  tendency 
for  the  head  to  draw  backward  is  not  so  much  a  question  of  the  effects 
of  the  virus  and  its  toxins  as  it  is  the  effect  upon  the  nerve  centres  through 
congestion  by  obstructed  blood  and  lymph  channels. 

The  involvement  of  the  lymphatics  is  due  in  the  first  place  to  the 
more  ready  infection  and  conveyance  of  the  virus  by  the  fact  that  the 
tissues  in  which  these  vessels  are  found  were  devitalized  by  obstructed 
or  impeded  circulation. 

The  normal  tissues  in  the  pharyngeal  and  nasal  regions  of  a  child 
will  not  harbor  nor  convey  to  the  same  extent  the  virus  as  in  the  case  of 
a  child  in  which  adenoid  growths  and  diseased  tonsils  are  found.  The 
child  with  polypi  and  congested  turbinate  processes  will  likewise  harbor 
germs  and  propagate  them  in  a  soil  that  is  suitable  for  germ  development 
through  obstructed  lymph  and  blood  channels. 

The  cause  of  this  static  condition  in  the  sinuses  of  the  head  and 
the  membranes  lining  these  as  well  as  lining  the  pharyngeal  region  may 
be  due  to  a  variety  of  lesions.  There  is  always  a  possibility  of  hereditary 
weakening  or  diathesis  with  nervous  instability,  but  we  will  discuss  here 
the  part  the  osseous  lesions  play  in  the  role  of  primary  causative  factors. 

The  drainage  of  the  lymphatics  of  the  head  and  neck  is  quite  the 
same  on  both  sides.     Below  the  neck  and  for  the  rest  of  the  body  we 


56 


Lymphatics 


Plate  IX.  The  Ijinph  spaces  found  in  the  membranes  of  the  cord  are 
numerous.  Right  lateral  view  of  cord  and  the  formation  of  spinal 
nerves.  The  Ijonph  bathing  the  cord  and  spinal  nerves  is  found  in 
abundance. — (1)  Anterior  horn.  (2)  Posterior  horn.  (3)  Anterior 
median  fissure.  (4)  Posterior  spinal  nerve  roots.  (.5)  Ligamentum  den- 
ticulatum.  (6  &  8)  Dura  mater.     (.7)  Posterior  ganglion. 


Acute  Poliomyelitis  57 

find  a  vastly  different  proposition.  The  lymphatics  of  both  sides  of 
the  head  and  neck  tend  to  pass  downward  to  a  common  collecting  centre, 
the  subclavian  veins.  The  superficial  communicate  with  the  deep,  and 
the  lymphatics  of  one  side  communicate  in  some  instances  with  those  of 
the  opposite  side.  Normally  the  nodes  are  not  over-sensitive  unless 
pressed  upon.  Induration  is  pathological  if  found  to  any  extent.  The 
same  rule  that  governs  the  freedom  of  circulation  of  blood  is  more  or 
less  applicable  to  that  of  the  lymph  channels.  Lesions  that  contract 
muscular  tissue  will  obstruct  lymph  channels  the  same  as  thej'^  will  ob- 
struct the  blood  vessels.  Not  all  lymphatics  have  vasomotors  supplying 
them,  it  is  true,  but  there  are  other  ways  of  obstructing  the  flow  of  lymph 
and  blood  than  through  the  vasomotor  nerves.  The  lesions  mentioned 
under  the  heading  of  "Cervical"  in  the  preceding  chapter  are  applicable 
to  lymph  channels  as  well  as  to  the  blood  vessels.  The  lesions  that 
produce  a  congested  condition  of  the  tonsils  will  invariablj'^  affect  the 
lymphatics  that  are  so  abundant  in  this  region.  The  lymphatic  tissues 
that  form  the  outer  and  inner  defences  of  the  naso-pharyngeal  region 
suffer  obstruction  and  nodular  enlargement  whenever  there  is  venous 
stasis. 

The  involvement  of  the  membranes  of  the  sinuses  of  the  head  are 
either  secondarily  or  simultaneously  affected  through  a  vascular  dis- 
turbance in  the  vault  of  the  phaiynx  and  the  region  of  the  nose. 

The  congestion  in  the  membranes  protecting  the  central  nervous 
system  are  the  effects  ^f  lymph  and  blood  vessel  obstruction  through  a 
lesion  of  some  nature — osseous  or  otherwise.  Before  congestion  there 
must  be  obstruction,  and  before  invasion  and  toxic  poisoning  from  virus 
there  must  be  a  suitable  soil  or  else  the  tissues  would  produce  an  abortive 
condition. 

Thus  we  see  first,  last  and  always  the  greatest  preventative  measure 
in  infection  of  any  nature  will  be  the  maintenance  of  normal  circulation 
both  in  the  lymph  channels  and  in  the  blood  vessels.  This  accounts  for 
the  numerous  cases  of  the  abortive  type  of  infantile  paralysis,  and  also 
the  noted  fact  that  in  many  instances  only  one  or  possibly  two  in  a  family 
of  several  children  contract  the  contagion;  the  others  not  becoming 
infected. 

Fortunately,  the  microorganism  of  infantile  paralysis  does  not  attack 
children  as  numerically  as  the  germs  that  are  connected  with  some  of 
the  other  and  more  common  diseases.  In  scarlet  fever,  measles,  whoop- 
ing cough,  etc.,  there  seems  to  be  a  condition  that  makes  the  contagion 
spread  with  a  more  decided  virulence.  It  is  not  uncommon  to  see  these 
children's  diseases  go  right  through  the  family. 


58 


Lymphatics 


Plate  X.  Anterior  view  of  the  cord  and  membranes.  The  lymph  bathes 
all  these  cells  and  tissues.  (1)  Posterior  horn.  (2)  Anterior  horn.  (3) 
Spinal  nerve  with  covering.  (4)  Dura  mater.  (5)  Turned  back.  (6) 
Spinal  cord  bared.  (7)  Arachnoid.  (8)  Anterior  nerve  roots.  (9,  10) 
(Top  number)  Lateral  surface  of  cord.  (10)  Anterior  nerve  passing 
through  dura  mater. 


Acute  Poliomyelitis  59 

In  infantile  paralysis  the  central  nervous  system  is  directly  involved, 
and  the  child  who,  due  to  lowered  tissue  resistance  from  spinal  lesions 
and  other  conditions,  furnishes  the  most  suitable  tissue  soil,  is  the  one 
that  will  be  the  victim.  The  others  may  have  the  germs  in  their  mucous 
membranes,  but  the  soil  is  not  favorable  to  infection  and  they  will  have 
simply  an  abortive  type  or  will  not  be  affected  in  the  least. 

The  obstruction  of  the  lymphatics  may  be  due  to  a  secondary  con- 
dition. The  presence  of  stasis  in  the  region  of  the  tonsils  may  be  some- 
what chronic  in  nature.  There  may  be  repeated  attacks  of  tonsillitis 
which  may  last  only  a  day  or  two.  The  disturbance  may  be  almost 
wholly  vascular.  Should  the  obstruction  persist  and  the  lymph  nodes 
become  enlarged  there  will  be  a  lymphatic  involvement  that  w' 11  tend 
to  complicate  matters.  Infection  will  be  a  natural  sequence.  The 
correction  of  an  atlas  or  axis  lesion  that  will  remove  any  disturbance  to 
the  superior  cervical  ganglion  with  its  postganglionic  fibres  that  control 
the  vasomotors  to  that  region  where  stasis  has  been  present  will  re- 
establish normal  lymph  flow. 

Lymphatic  involvement  may  be  secondary  to  a  vasomotor  dis- 
turbance to  the  blood  vessels  in  the  same  region  where  congestion  ex- 
ists.  The  hyoid  bone  slightly  misplaced  will  put  tension  upon  one  set 
of  the  muscles  attached  to  it  and  cause  not  only  venous  stasis  but  a 
blocking  of  the  lymph  chamjels,  and  as  a  result  we  will  note  nodular 
enlargement  in  the  lymphatic  chains.  The  enlargement  of  the  nodes 
in  the  region  of  the  mastoid  may  be  due  to  an  obstruction  of  the  lym- 
phatic channels  in  the  region  of  the  clavicle.  The  backward  luxation 
of  the  clavicle  with  a  subluxated  first  rib  may  obstruct  the  drainage  of 
the  lymph  into  the  subclavian  veins. 

The  middle  cervical  ganglion  may  be  involved  and  we  may  have 
a  thyroid  disturbance  as  well  as  cardiac  irregularity  through  a  cervical 
lesion.  This  may  in  turn  cause  pressure  by  thyroid  enlargement  upon 
the  lymph  channels  and  produce  toxic  poisoning  of  the  membranes  and 
tissues  in  the  throat,  head  and  central  nervous  system. 

The  presence  of  an  aneurysm  may,  through  mechanical  pressure, 
cause  a  greater  disturbance  than  any  single  osseous  lesion.  A  cervical 
rib  may  cause  irritation  of  the  brachial  plexus  and  the  sympathetic  sys- 
tem that  will  not  be  relieved  until  surgical  measures  are  used.  Not  all 
disturbances  are  from  osseous  lesions  in  the  way  of  vertebral  rotations 
or  subluxations,  and  not  all  disturbances  are  from  local  interferences. 
The  lymph  channels  may  be  affected  and  infected  through  disorders 
in  the  axillary  and  mammary  region,  or  even  lower  down.  There  is  a 
communication  between  the  lymph  channels  of  the  thorax  and  cervical 


60 


Lymphatics 


Platk  XI.  Posterior  view  of  spinal  cord.  The  lymph  blocked  in  acute 
poliomyelitis  prevents  the  nerve  and  cord  cells  from  functioning  prop- 
erly. 


Acute  Poliomyelitis  61 

region  back  of  the  clavicles.  That  is  why  no  diagnosis  is  complete  that 
does  not  include  a  complete  systemic  survey  in  each  instance.  The 
high  temperature  of  a  child  or  an  adult  may  be  lowered  by  a  single  ad- 
justment in  the  upper  thoracic,  or  a  similar  effect  may  be  brought  about 
through  the  correction  of  a  cervical  lesion.  The  idea  is  to  determine 
the  exciting  cause,  if  from  a  lesion,  and  correct  the  irregularity  if  it  is 
at  all  possible  to  do  so. 

Lymphatics  of  the  Thorax  and  Abdomen 

Infection  almost  invariably  complicates  the  lymphatic  system. 
We  are  prone  to  think  only  of  the  veins  conveying  impure  blood  and 
producing  congestion  and  stasis,  but  we  must  remember  always  that  the 
lymph  channels  are  the  conveyors  of  toxic  products,  and  blockage  in  a 
node  or  number  of  nodes  will  affect  the  elimination  or  retard  the  dis- 
semination of  toxic  products. 

There  is  a  possibility  of  the  virus  found  in  infantile  paralysis  cases 
entering  through  the  bronchial  tubes  and  infecting  the  tissues  in  rela- 
tion to  the  roots  of  the  lungs.  Dust  particles  include  germs,  and  their 
entrance  via  the  bronchioles  may  cause  infection  and  enlargement  of 
the  lymph  nodes  in  that  area. 

There  is  a  possibility  of  the  virus  or  microorganisms  of  infantile 
paralysis  lodging  and  becoming  scattered  through  the  lymphatics  in  the 
thoracic  region  in  relation  to  the  bronchial  terminations. 

Around  the  cord  the  pia  mater  and  arachnoid  harbor  lymph  spaces. 
These  spaces  are  in  communication  with  the  vessels,  and  it  is  through 
them  infection  enters  the  cord  substance. 

In  the  abdomen  below  the  diaphragm  the  cisterni  chyli  is  located. 
Into  this  receptum  the  intestinal  lymphatic  drainage  enters  and  the 
beginning  of  the  thoracic  duct  is  found.  This  duct  collects  from  the 
abdominal  viscera  and  passes  through  the  diaphragm  in  relation  to 
the  aorta. 

The  lacteals  carry  away  some  of  the  chyle  absorbed  from  the  small 
intestines  and  convey  the  substance  to  the  thoracic  duct  that  passes 
upwards  to  empty  into  the  subclavian  vein  on  the  left  side. 

The  peritoneum  is  a  lymphatic  sac  in  one  respect.  The  amount  of 
absorption  that  takes  place  in  the  peritoneum  is  great. 

The  food  taken  into  the  stomach  containing  the  microorganisms 
of  infantile  paralysis  are  readily  absorbed  by  the  lymph  channels  and 
conveyed  to  the  blood  circulation. 

The  possibilities  of  mixed  infection  is  worthy  of  consideration. 
If  a  lymph  channel  is  already  infected  by  other  germs,  it  is  in  no  condi- 
tion to  combat  the  virus  of  infantile  paralysis  should  it  be  absorbed. 


62 


Lymphatics 


Plate  XII.  Vascularization  of  a  section  of  the  spinal  cord,  showing  the 
three  spinal  arteries  and  correlating  spinal  branches  from  the  intercostal. 
The  cerebro-spinal  fluid  is  of  a  lymph  formation,  and  the  area  is  bathed 
by  this  fluid  also. 


Acute  Poliomyelitis  63 

The  lymphatic  system  is  in  danger  of  blockage  and  sluggishness  the 
same  as  the  vascular  system.  The  normality  of  the  nodes  and  channels 
of  the  lymphatic  system  will  depend  to  a  great  extent  upon  the  condi- 
tion of  the  blood  vessels  and  the  tone  of  their  walls.  If  we  find  stasis 
in  the  mesenteric  blood  vessels  we  are  likely  to  find  nodular  enlarge- 
ment of  the  lymphatic  system.  The  numerous  nodes  found  in  the  mesen- 
tery and  along  the  vessels  of  the  bowels  are  normal  only  so  long  as  the 
blood  stream  to  and  from  the  abdominal  viscera  is  normal.  A  diseased 
organ  is  one  that  has  a  disturbed  circulation  regardless  of  the  cause. 
If  an  organ  is  functioning  abnormally  we  invariably  find  its  vascular 
supply  disturbed.  If  an  organ  is  mechanically  interfered  with  we  also 
find  the  circulation  to  that  organ  affected.  The  cause  being  removed, 
the  circulation  may  once  more  be  re-established. 

The  infection  of  an  organ  is  through  its  vascular  channels,  either 
the  blood  or  the  lymph.  The  better  the  circulation  the  less  chance  of 
germ  invasion.  The  more  perfect  the  assimilative  mechanism  the  less 
liable  the  virus  to  be  disseminated  and  propagated. 

Lymph  spaces  are  found  around  the  cord  in  all  regions.  The  vas- 
cularization of  the  cord  is  complete  at  every  segment.  The  entrance  of 
germs  at  any  point  is  possible.  The  normality  of  the  lymph  spaces  in 
relation  to  the  pia  mater  will  depend  to  a  great  extent  upon  the  normality 
of  the  vascular  system  in  relation  to  the  cord  and  its  membranes. 

If  there  exist  lesions  at  any  point  along  the  length  of  the  cord  we 
at  once  find  a  lowered  tissue  resistance  to  that  area  of  the  cord. 

There  may  be  a  trophic  disturbance  or  a  vasomotor  instability  to 
the  vessel  walls,  or  we  may  find  stasis  from  a  contractured  musculature 
that  will  block  the  lymph  spaces.  In  any  of  these  conditions  the  tissue 
vitality  will  be  undermined  and  invasion  is  more  apt  to  take  place. 

In  the  thoracic  region  we  may  find  costal  lesions  as  well  as  verte- 
bral. The  relation  of  the  intercostal  vessels  to  the  ribs  may,  in  a  costal 
subluxation,  so  disturb  the  sympathetic  ganglia  that  the  tissues  around 
the  foramina  will  become  irritated,  and  this  will  extend  into  the  cord 
through  the  blood  channels. 

The  blockage  of  one  vessel  to  the  cord  and  membranes  may  so  lower 
the  nerve  and  cell  integrity  that  a  cord  segment  will  become  readily  in- 
fected  by  the  virus. 

Remember  that  the  cord  segments  and  their  cells  must  be  kept 
at  a  certain  tone  from  a  vascular  standpoint  or  else  the  cells  will  not 
function  normally.  In  the  ventral  portion  of  the  grey  matter  of 
the  cord  the  motor  cells  send  forth  their  efferent  impulses,  and  the  mus- 
cular tone  of  the  limbs  will  depend  upon  the  normality  of   these  im- 


64 


Lymphatics 


Plate  XIII. 
General  Scheme  of  Lymphatics. 


Acute  Poliomyelitis  65 

pulses  for  their  strength  and  motion.  The  lowered  tone  through  dis- 
turbed  vascularization,  plus  the  invasion  of  the  virus  or  its  toxins,  even 
in  a  mild  or  abortive  case,  will  cause  a  disturbance  to  the  efferent  tracts 
in  proportion  to  the  degree  m  which  the  cells  resist  the  attack. 

In  the  more  severe  cases  of  infantile  paralysis,  where  exudation  ac- 
companies congestion,  we  note  a  marked  destruction  of  the  motor  area. 

If  the  spinal  arteries  and  veins  are  obstructed  to  any  extent  the 
lymph  spaces  are  occluded,  and  nature's  effort  to  clear  the  condition  is 
sorely  handicapped.  Thus  we  see  the  prime  importance  of  keeping  a 
child's  spinal  tissues  up  to  normal  so  that  should  the  virus  gain 
entrance  to  the  body  there  will  not  be  lowered  tissue  resistance  in  the 
region  of  the  central  nervous  system. 

The  region  of  the  diaphragm,  with  its  many  openings  for  the  passing 
of  nerves,  vessels,  tubes,  etc.,  is  of  interest.  The  presence  of  lower  rib 
lesions  or  vertebral  misplacements  may  so  affect  the  attachments  of 
the  diaphragm  and  its  crura  that  the  openings  found  in  its  central  tendon 
and  in  the  region  in  relation  to  the  vertebral  column  may  cause  undue 
pressure  or  obstruction  to  these  various  tubes,  vessels  and  nerves. 

The  veins  and  thoracic  duct  are  passing  upward;  the  nerves,  aorta 
and  esophagus  are  going  downward.  All  have  their  functions  and  any 
minor  obstruction  may  cause  a  systemic  disturbance. 

The  thoracic  duct  has  a  few  valves  to  prevent  backward  flow.  It 
is  a  long  tube,  and  gravity  is  against  it  the  same  as  in  the  saphenous 
veins.  This  duct  has  its  vascular  supply  and  nerve  tone,  although  it 
has  not  the  marked  muscular  tissue  within  its  walls  that  is  found  in 
the  blood  vessel  walls.  The  thoracic  duct  is  a  great  collecting  system 
and  the  flow  of  lymph  must  be  emptied  into  the  veins  as  regularly  as 
possible. 

From  the  fact  that  the  lymphatic  system  has  to  deal  with  toxic 
products,  we  must  at  all  times  determine  the  condition  of  this  duct  and 
see  that  no  lesion  exists  that  will  in  any  way  affect  its  walls  or  its  con- 
veying properties. 

The  cisterni  chyli  is  located  in  front  of  the  second  and  third  lumbar 
vertebrae.  Lesions  that  are  found  at  this  region,  or  even  higher,  in- 
cluding lower  costal,  may  have  a  marked  effect  upon  the  receptive  prop- 
erties of  this  collecting  system. 

The  drainage  of  the  mesenteric  nodes  into  this  cistern  will  depend 
upon  the  normality  of  the  blood  vessel  circulation.  The  presence  of 
obstipation,  with  poor  peristaltic  action,  the  finding  of  adhesions  or  the 
noting  of  growths  and  thickening  of  the  tissues,  all  have  a  bearing  upon 
the  lymphatic  system.     Splanchnoptosic  conditions  will  affect  drainage 


66 


Lymphatics 


Plate  XIV. — Section  of  the  spine,  A  vertebra  with  the  spinal  cord  and 
its  membranes.  The  small  cut  to  the  left  is  an  enlarged  section  of  the 
cord.     Lymph  spaces  are  found  in  this  area. 


Acute  Poliomyelitis  67 

and  obstruct  the  lymph  channels.  This  will  lower  the  general  tone 
of  the  tissues.  In  children  colic,  convulsions  and  constipation  will  lower 
the  vitality. 

The  tissues  of  the  entire  body  in  the  child  are  not  only  growing,  but 
must  be  sustained  in  the  way  of  complete  nourishment  as  well.  In  the 
adult  the  growth  is  complete  and  sustenance  alone  is  required.  The 
activity  of  a  child  is  much  greater  than  in  the  adult,  as  a  rule.  The  re- 
siliency  of  the  tissues  is  greater,  and  the  bones  are  not  as  yet  completely 
ossified.  He  takes  up  shock  better  than  an  adult,  and  the  nerves  do  not 
seem  to  suffer  from  accidents  as  do  those  of  the  adult. 

The  common  point  of  tissue  irritability  is  when  we  find  a  lesion 
from  a  fall  or  strain.  The  disturbance  to  the  vessels  and  nerves,  unless 
the  proper  adjustment  is  made,  will  continue  to  lower  tissue  resistance 
through  nerve  irritation.  If  the  sympathetic  chain  is  involved  through 
its  connection  with  the  spinal  nerves,  the  vasomotors  will  suffer  from  im- 
peded circulation,  and  the  impulses  will  become  irregular. 

The  spine  of  a  child  from  the  time  it  is  born  must  be  inspected  if  we 
wish  to  keep  him  free  from  lesions  and  scoliosis.  Some  children  grow  up 
with  almost  perfectly  aligned  spines,  while  others,  through  traumatism, 
suffer  irregularities  that  adjustment  alone  will  rectify. 


68 


Lymphatics 


Platk  XV.    The  spinal  cord  and  nerves  exposed.     The  lymph   bathes  the 
entire  tract. 


CHAPTER  FOUR 

LYMPHATICS  OF  THE  THORAX 

The  Lymphatics  of  The  Lungs  and  Pleura 

The  most  perplexing  part  of  the  lymphatic  system  to  a  student  is 
possibly  that  of  the  thoracic  region.  It  is  easy  to  understand  the  tho- 
racic duct  and  its  cluster  of  tubes  at  the  lower  part,  the  cysterni  chyli,  but 
the  drainage  of  the  intercostals,  the  lungs,  bronchi,  esophagus,  heart 
and  diaphragm  is  difficult  to  comprehend.  There  seems  to  be  a  lack 
of  plates  in  most  texts  on  anatomy  to  furnish  object  lessons.  In  a  gen- 
eral way  a  few  of  the  channels  are  shown,  but  the  student  is  still  at  a 
loss  to  comprehend  just  how  there  may  be  ducts  that  convey  lymph 
from  these  various  organs  and  tubes  as  the  bronchi,  esophagus  and  aorta, 
and  still  be  independent  of  the  great  thoracic  duct. 

Let  us  open  this  discussion  by  saying  that  the  lymph  must  eventually 
reach  the  subclavian  veins,  or  possibly  the  innominate  veins.  The  stu- 
dent is  familiar  with  the  fact  that  the  lymph  flow  to  the  subclavian  veins 
empties  through  two  main  ducts,  the  right  lymphatic,  and  the  thoracic 
duct.  There  are  other  points  of  entry  separate  from  these  two  main 
ducts ;  sometimes  two  or  three.  For  instance,  the  internal  mammary  ducts 
usually  empty  into  the  subclavian  as  distinct  ducts.  The  mediastinal 
may  join  the  mammary  or  empty  separately,  but  they  all  enter  the  veins 
at  some  point  within  a  small  radius.  It  may  be  on  the  upper  surface,  the 
anterior,  or  even  inferior  surface  of  the  vein.  Now  let  us  take  up  the 
drainage  of  the  bronchial  nodes  first.  Around  the  lower  part  of  the 
trachea  and  over  the  surface  of  the  bronchi  the  tracheo-bronchial  nodes 
are  scattered.  At  the  angle  of  the  bronchi  and  also  where  the  bronchi 
divide  nodes  are  present.  They  even  extend  to  the  bronchioles  but  not 
into  the  alveoli. 

All  of  these  nodes  have  efferents  and  must  be  drained.  The  drain- 
age is  upward  toward  and  into  the  subclavian  veins.  These  nodes  drain 
the  lung  tissue  as  well  as  the  bronchi  and  trachea.  The  lymph  from 
the  heart  reaches  these  nodes  also  in  part  at  least. 

The  cfferents  from  these  nodes  join  in  some  instances  those  of  the 
internal  mammary  and  pass  on  to  the  subclavian  veins.  The  right 
may  enter  the  right  lymphatic  duct,  or  may  enter  the  subclavian  vein 
direct.  On  the  left  side  the  thoracic  duct  may  receive  the  mammary 
efiferents  or  the  subclavian  vein  receive  the  drainage  directly.  The 
lungs  have  their  superficial  and  deep  plexuses  of  vessels,  but  they  all 
drain  toward  the  hilum  which  receives  the  lymph  flow  of  the  lung  tissue. 

—69— 


70 


Lymphatics 


Plate  XVI.  The  internal  mammarj'  lymph  chain  collects  lymph  from  the 
anterior  intercostal  spaces,  inner  areas  of  breasts,  some  from  the  pleura, 
and  from  the  upper  anterior  surface  of  the  liver. 


Thorax  7 1 

From  these  nodes  the  tracheo-bronchial  nodes  collect  and  through  their 
efTerents  eventually  empty  into  the  internal  mammary  or  mediastinal 
nodes  to  be  conveyed  to  the  veins  on  either  side.  The  superficial  and 
deep  lymph  vessels  in  the  lungs  anastomose  only  at  the  hiluni,  at  the 
root  of  the  lung,  on  either  side.  The  pleura  has  a  more  distinct  drain- 
age as  the  visceral  layer  drains  into  the  lung  afferents  on  its  surface, 
while  the  parietal  lymph  streams  are  collected  according  to  the  regions 
they  are  located  in.  In  front  they  are  collected  by  the  internal  mammary 
after  passing  through  the  intercostal  muscle  lymphatics,  while  the  lower 
parietal  lymph  vessels  may  join  with  the  vessels  of  the  diaphragm.  In 
the  posterior  region  the  medisatinal  nodes  collect  the  lymph  from  the 
parietal  part  of  the  pleura. 

Thus  we  see  how  simple  the  drainage  is  if  we  remember  the  col- 
lecting tubes  of  the  different  regions. 

Dr.  Snyder,  in  his  chapter  on  the  lungs,  outlines  very  nicely  the 
drainage  of  these  tissues.  In  this  general  discussion  we  wish  only  to 
give  an  idea  of  the  drainage,  so  that  we  may  refer  to  some  features  of 
the  applied  anatomy  of  the  same. 

In  the  first  place,  we  wish  to  emphasize  the  importance  of  free  lymph 
drainage  in  the  nodes  that  collect  and  send  forward  the  lymph.  We 
have  mentioned  in  another  chapter  the  fact  that  lung  infection  is  usually 
downward  from  the  throat.  It  is  easy  for  a  catarrhal  condition  to  work 
its  way  downward,  also  infection  and  congestion. 

The  nodes  in  children  are  of  a  pinkish  tint,  but  in  the  adult  they 
often  become  dark  or  black  and  enlarged.  If  these  blocked  nodes  be- 
come infected  with  tubercular  germs,  suppuration  may  take  place,  and 
the  discharge  may  be  thrown  into  the  bronchi.  This  will  infect  the  lung 
tissue  in  time,  as  only  part  of  the  discharge  can  be  coughed  up.  The 
breaking  down  of  the  nodes  is  often  the  result  of  dust  laden  particles 
being  conveyed  to  the  bronchial  tubes. 

Now,  we  come  to  the  osteopathic  idea  of  keeping  these  nodes  in 
tone.  We  cannot  keep  people  away  from  dust  and  irritating  inhala- 
tions, but  we  can  keep  the  pulmonary  and  bronchial  vessels  and  tissues 
toned  up  through  our  method  of  adjustment. 

The  contour  of  the  chest  wall  may  have  a  lot  to  do  with  the  condi- 
tion of  the  blood  and  lymph  supplj-  within.  A  flat-chested  person  has 
not  the  chance  for  resistance  that  a  well  rounded  chest  has.  The  sagging 
of  the  ribs  may  be  due  to  lack  of  tone  in  the  muscles,  but  we  find  that  more 
often  there  is  either  a  curvature  or  one  or  more  lesioned  areas. 

To  correct  posture  we  must  first  secure  spinal  alignment.  We  may 
have  to  start  at  the  innominates  and  work  from  that  basic  standpoint. 


72  Lymphatics 

As  we  secure  normality  of  the  spine,  we  can  elevate  the  ribs  and  secure 
better  vasomotor  control.  Adjustment  of  the  upper  thoracic  area  will 
add  tone  to  the  lung  tissue  as  the  circulation  will  be  more  regular.  Where 
we  secure  a  good  arterial  supply  we  also  insure  a  better  venous  drain- 
age. We  are  now  reaching  the  point  where  we  can  work  to  advantage 
on  the  lymph  stream.  We  pointed  out  the  various  drainage  tubes,  and 
it  is  to  the  end  of  securing  a  better  lymph  flow  that  we  now  work.  The 
nodes  are  secondaiy  in  'mportance  in  some  respects  to  the  efferent  flow 
of  lymph.  Unless  we  have  a  free  drainage  we  cannot  expect  to  relieve 
the  over-burdened  lymph  nodes.  If  it  were  possible  to  keep  the  thorax 
in  normal  position,  vertebrae,  ribs  and  sternum,  we  would  have  little 
difficulty  in  regulating  the  blood  supply.  The  good  blood  coursing 
through  the  vessels  and  tissues  would  sustain  a  tone  that  would  prevent 
germs  from  gaining  a  hold  on  the  nodes.  The  nodes  are  usually  normal 
if  the  blood  circulation  is  perfect  or  nearly  so.  You  will  recall  the  gen- 
erous blood  supply  that  most  nodes  have.  It  is  this  supply  that  keeps 
the  nodes  capable  of  resisting  invasion.  If  we  work  to  the  end  of  regu- 
lating blood  supply  to  nourish  and  drain,  vascularly,  the  nodes,  we  will 
find  we  have  accomplished  much.  The  sinuses  within  the  nodes  are 
kept  normal  mainly  through  the  blood  that  supplies  each  node.  Here 
is  where  we  check  the  points  of  invasion.  A  node  breaks  down  because 
it  has  lessened  resistance  through  faulty  circulation  of  the  blood.  Thus 
we  have  the  proposition  of  keeping  up  the  tone  of  the  lymph  nodes  and 
vessels  through  vasomotor  control  of  the  blood  vessels.  This  point  is 
seldom  if  ever  emphasized,  but  it  holds  good  in  any  part  of  the  body 
where  nodes  exist. 

The  entrance  of  dust,  irritants,  poisons,  germs  or  foreign  substances 
of  any  nature  into  the  nodes  may  be  offset  to  a  large  degree  by  the  regu- 
lation of  the  blood  supply  to  and  from  the  nodes. 

In  weak-chested  people  we  must  first  of  all  secure  alignment,  then 
good  posture,  and  finally  good  tone  through  indirect  vasomotor  control. 

The  efferents  from  the  pleura  include  the  internal  mammary,  as 
we  have  said.  The  internal  mammary  receives  part  of  the  intercostal 
drainage.  If  there  arc  one  or  more  costal  lesions  a  proportionate  block- 
age will  result.  If  the  scaleni  muscles  are  tensed  through  cervical  lesions, 
and  the  first  and  second  ribs  drawn  upward,  there  is  a  possibility  of  in- 
terference with  lymph  drainage  from  a  portion  of  the  lungs  and  pleura. 

The  vessels  crossing  the  fii-st  ribs  may  be  interfered  with  and  the 
thoracic  duct  on  left  side  drawn  in  a  position  to  check  drainage  into  the 
vein.  The  vessels  to  the  bronchial  tubes  and  lungs  are  controlled 
through  va.somotor  centres  that  may  be  influenced  in  the  upper  thor- 


Thorax 


73 


Plate  XVII.     Lymph  drainage  of  the  larynx,  trachea,  bronchial  tubes  and 
bronchioles. 


74  Lymphatics 

acic  sections.    The  nerves  to  the  lungs  may  be  influenced  by  cervical 
lesions  as  well  as  upper  thoracic. 

Blockage  of  the  lymph  stream  in  the  neck  or  around  the  trachea 
may  interfere  with  the  lung  efferents.  The  tracheo-bronchial  nodes 
and  the  mediastinal  may  be  checked  in  their  drainage  through  congested 
membranes  and  tissues.  This  calls  for  a  better  vascular  regulation. 
These  two  systems  work  together  to  clear  any  area  or  region.  We  must 
work  to  secure  good  lymph  drainage  by  not  only  removing  any  inter- 
ference with  the  efferents  from  the  nodes,  but  through  the  reducing  of 
congestion  around  the  nodes  and  efferents. 

The  clavicles  have  much  to  do  with  interference  with  lymph  drain- 
age at  times.  We  find  a  clavicle  in  some  instances  not  in  true  align- 
ment, occssionally  backward  at  external  end.  It  is  well  to  see  that 
they  are  not  drawn  out  of  line.  There  are  so  many  vessels,  nerves, 
tubes,  etc.,  passing  through  the  upper  thoracic  opening  that  we  need 
to  determine  if  there  is  room  for  these  various  structures;  also,  note  the 
presence  of  congested  or  thickened  areas.  The  person  with  a  goitre 
may  have  a  weak-chested  condition  not  only  through  disturbed  nerve 
impulses,  and  irregular  blood  flow,  but  by  lymph  blockage  as  pointed 
out  in  the  chapter  on  the  thyroid  gland. 

The  broncho-pulmonary  nodes  aire  usually  over-burdened  at  their 
best.  It  is  a  question  whether  any  one 'has  normal  nodes  in  this  region. 
Inhalations  and  catarrhal  exudates  iand  infections  by  tubercular  germs, 
even  though  practically  latent,  all  contribute  to  keep  the  nodules  in  the 
region  of  the  hilum  in  an  overtaxed  state.  The  alveoli  have  no  nodes, 
but  the  lymph  vessels  are  found  in  the  lung  tissue.  The  correcting  of 
lesions  that  will  insure  better  respiration  will  do  much  to  clear  the  lymph 
vessels. 

Any  interference  with  the  intercostal  muscles  or  costovertebral 
attachments  will  shorten  breathing  and  correspondingly  impair  lymph 
drainage.  Very  few  people  breathe  properly,  and  when  they  contract 
colds  or  have  a  cough  they  almost  immediately  assume  a  faulty  posture. 
This  drooping  of  the  chest  not  only  affects  the  intercostal  lymph  vessels 
but  retards  the  flow  of  lymph  in  the  thoracic  duct  and  mediastinal 
nodes.  The  erect  posture  relieves  the  pressure  and  the  efferents  con- 
vey their  lymph  more  readily. 

We  have  not  given  the  lymph  flow  sufficient  thought  in  the  past. 
We  have  never  realized  the  full  significance  of  free  lymph  drainage.  The 
lymphatic  system  peripherally  being  a  blind  end  or  closed  system,  so 
to  speak,  without  any  force  to  start  the  flow,  as  in  the  vascular  system, 
we  have  felt  that  it  simply  cleared  itself  according  to  the  physiological 
activities  found  in  various  conditions. 


Thorax  75 

The  lymphatics  start  their  collecting  system  in  the  capillaries  and 
it  is  only  through  indirect  tone  furnished  by  the  tissues  and  vasomotors 
that  control  the  vessels  that  we  can  expect  a  normal  flow  of  lymph.  Only 
the  numerous  valves  prevent  the  lymphatics  from  becoming  thoroughly 
blocked.  At  all  times  work  to  secure  good  lymph  drainage.  By  so 
doing  you  invariably  at  the  same  time  secure  better  vascular  regulation. 

The  lymph  stream  is  the  weak  member  in  the  circulatory  system, 
and  we  must  study  out  every  method  of  securing  better  drainage  of 
lymph  in  order  that  the  nodes  will  not  become  blocked  and  indurated. 

We  depend  upon  the  lungs  to  purify  the  blood,  but  we  must  not 
forget  that  there  is  a  separate  set  of  blood  vessels  that  supply  the  lung  tis- 
sue, and  that  these  tissues  must  be  drained  also  by  not  only  the 
veins  but  the  lymphatics. 

Unless  we  can  keep  the  broncho-pulmonary  lymph  nodes  clear  the 
areation  of  the  blood  in  the  alveoli  and  lung  tissues,  will  not  be  sufficient 
to  prevent  breaking  down  of  the  general  system  through  a  checking 
and  final  infection  in  the  nodes  around  the  bronchi.  The  aeration  of 
the  blood  in  the  lungs  is  no  more  important  than  the  preventing  of  in- 
duration in  the  nodes  that  drain  the  lung  tissue. 

To  have  good  general  circulation  and  tone  throughout  the  body  we 
must  have  cleared  afi'erents  and  efferents  in  the  broncho-pulmonary 
nodes. 

Lymphatics  of  the  Axillary  Region 

The  phj^sician  is  more  familiar  with  this  region,  lymphatically  con- 
sidered, than  any  other  except  the  cervical.  It  is  so  common  to  find 
enlargement  of  the  axillary  nodes  in  infectious  diseases  and  after  vac- 
cination that  his  attention  is  called  to  this  area  frequently. 

The  possibility  of  lymph  blockage  at  this  point  makes  one  think  of 
the  efi"erents  that  lead  to  the  subclavian  nodes.  These  nodes  empty  by 
vessels  on  the  right  side  into  the  subclavian  vein  or  directly  into  the  right 
lymphatic  duct.  Between  the  subclavian  nodes  and  the  terminal  drain- 
age point  the  subclavian  trunk  passes  between  the  vein  and  the  sub- 
clavius  muscle,  and  then  behind  the  clavicle.  On  the  left  side  the  trunk 
may  enter  the  thoracic  duct  or  empty  directly  into  the  subclavian  vein 
at  the  junction  with  the  jugular.  The  subclavian  muscle  may  be  in  a 
state  of  tension  from  a  subluxated  clavicle  or  through  disturbed  innerva- 
tion of  the  muscle.  These  lesions  will  retard  the  flow  of  lymph  in  the 
vessels. 

When  we  consider  the  deep  lymph  drainage  of  the  axillary-  region, 
its  drainage  of  bone,  periosteum,  ligaments,  muscles  and  other  tissues, 
we  get  an  idea  of  the  relative  importance  of  keeping  all  muscluar  con- 


76  Lymphatics 

tractures  at  a  minimum.  If  there  are  costal  lesions  they  will  affect 
lymph  drainage,  and  if  the  pectoral  muscles  are  tense,  we  must  expect 
a  similar  retardation  of  lymph  flow.  The  free  anastomosis  found  in 
the  lymph  vessels  of  the  arm,  as  elsewhere,  makes  the  lymph  drainage  of 
the  axillary  region  a  common  one.  The  central  group  of  nodes  in  this 
region  collect  from  a  vast  area  and  the  point  of  interest  lies  in  the  di- 
rection of  the  terminal  drainage  point.  The  supraclavicular  and  the 
subclavian  nodes  are  often  blocked.  Even  the  lower  cervical  nodes  are 
involved  when  the  axillary  are  enlarged.  Snow  refers  to  regurgita- 
tion in  malignant  cases  leading  to  retrosternal  involvement  and  secondary 
infection  of  the  head  of  the  humerus.  We  find  regurgitation  possible 
elsewhere  as  in  the  lymph  vessels  in  gastric  cancer.  This  simply  proves 
that  although  lymph  vessels  have  numerous  valves  there  may  be  re- 
gurgitations under  certain  conditions.  Going  back  to  the  lymph  drain- 
age  of  the  muscles  we  may  reach  and  influence  the  flow  of  lymph  through 
a  better  vasomotor  control  of  the  blood  vessels  that  supply  the  tissues 
and  nodes.  We  may  also  reach  the  lymph  drainage  through  correction 
of  lesions  that  remove  muscle  tension  over  and  around  the  lymph  ves- 
sels and  nodes.  This  will  call  for  adjustment  of  the  cervical  region  to 
insure  normal  tone  in  the  brachial  plexus.  Correction  of  upper  thor- 
acic and  rib  lesions  will  stimulate  vasomotor  and  trophic  centres. 
Costal  correction  will  regulate  the  upper  thorax  so  that  the  lymph  drain- 
age into  the  subclavian  veins  will  not  be  checked.  The  scaleni  may  be 
overtensed  through  cervical  lesions. 

Correct  posture  will  help  to  insure  good  lymph  drainage  from  the 
axillary  region.  The  lymph  vessels  and  nodes  often  are  attached  to  the 
sheath  of  the  veins.  They  follow  the  vessels  closely  in  many  instances. 
This  is  another  reason  why  we  should  keep  muscle  tension  at  a  mini- 
mum, as  a  tensed  muscle  will  interfere  with  the  blood  flow  and  a  thick- 
ening of  the  adjacent  tissues  may  block  the  lymph  flow  and  cause  an 
undue  toxic  effect  that  will  result  in  a  blocking  of  certain  lymph  nodes 
and  vessels.  The  axillary  region  is  an  active  one  in  that  the  use  of  the 
arms  cause  the  muscles  of  the  shoulder  and  pectoral  region  to  be  ac- 
tively engaged.  Normally  muscular  activity  aids  lymph  flow  as  well 
as  venous  flow.  It  is  when  there  is  axillary  adenitis  or  lymph  blockage 
in  the  afferents  that  motion  is  sometimes  disadvantageous  to  the  lymph 
stream.  The  mammary  area,  if  blocked,  will  check  the  flow  in  many 
of  the  vessels.  If  there  is  an  additional  axillary  blockage  the  retarded 
nmmmaiy  lymph  flow  will  cause  a  pectoral  disturbance  that  will  not 
clear  until  the  axillary  and  subclavian  nodes  are  reduced.  The  sub- 
clavian may  receive  mammary    lymphatics,  also  the  internal  mammary 


Thorax  *       77 

nodes  will  take  up  part  of  the  mammary  drainage,  but  it  is  through  the 
axillaiy  nodes  collecting  the  pectoral  lymph  that  we  must  look  for  drain- 
age when  we  find  tumors  forming  in  the  breast.  We  are  called  upon 
almost  constantly  to  reduce  these  "lumps."  If  there  is  no  malignant 
condition  we  are  reasonably  sure  of  reducing  them  by  axillary  drainage, 
unless  they  are  unduly  indurated. 

The  lessening  of  pectoral  muscle  tension  and  correction  of  costal 
lesions,  as  well  as  cervical  and  upper  thoracic  lesions,  to  insure  normal 
nerve  tone,  will  be  the  more  important.  Direct  manipulation  of  the 
axillary  nodes  is  contraindicated.  It  is  far  better  to  reduce  node  en- 
largement through  adjustment  of  lesions  as  outlined  above. 

Sometimes  a  lymph  vessel  from  the  mammary  gland  passes  through 
the  substance  of  the  pect oralis  major  leading  to  the  subclavian  nodes. 
If  there  is  faulty  innervation  to  this  muscle  the  undue  contraction  may 
check  the  lymph  flow. 

The  region  of  the  scapula  is  drained  by  efferents  into  the  axillary 
nodes.  We  now  see  what  a  large  area  these  nodes  in  the  axilla  collect 
from.  In  cases  of  scoliosis,  where  there  are  group  costal  lesions,  we  may 
find  a  sufficient  blockage  to  over-burden  the  nodes  of  the  axilla.  If 
there  is  a  goitre,  and  the  lower  cervical  nodes  are  enlarged,  we  may  find 
an  additional  pectoral  blockage,  especially  if  the  lymph  vessels  of  the 
upper  extremity  empty  into  the  two  large  terminal  trunks,  the  right 
lymphatic  and  the  thoracic.  It  takes  but  very  little  supraclavicular 
edema  to  interfere  with  terminal  drainage.  The  entire  arm  may  be 
affected.  Slight  puffiness  around  the  fingers  may  lead  us  to  suspect 
lymph  blockage  either  in  the  axillary  or  clavicular  regions.  The  small 
nodes  in  the  cubital  fossa,  or  the  epitrochlear  nodes  may  become  en- 
larged if  there  is  interference  above. 

The  establishing  of  better  circulation  in  the  arms  by  vasomotor 
tone  will  assist  in  clearing  up  a  lymph  sluggishness. 

The  cervical  area  must  be  cleared  first.  The  first  dorsal  nerve 
must  not  be  overlooked  as  a  branch  of  that  nerve  enters  in  the  nerve  plex- 
us. The  first  rib  is  sometimes  sHpped  sufficiently  to  cause  a  lymph  dis- 
turbance. 

Test  out  the  arm  movement  to  be  sure  that  the  tendon  of  the  bi- 
ceps is  absolutely  in  the  groove,  and  that  there  is  a  good  free  arm  move- 
ment. 

Neuritis  is  so  common  that  we  find  many  mild  cases  in  every  day 
practice.  Well  marked  cases  are  fairly  common  also.  The  lymph 
flow,  if  checked,  will  poison  or  irritate  the  nerves  as  there  is  a  certain 
amount  of  lymph  fluid  within  the  sheath  of  the  nerve.     In  fact,  I  am  in- 


78       *  Lymphatics 

clined  to  believe  that  neuritis  and  tic  are  lymphatic  disorders.  In  ex- 
perimenting with  both  of  these  maladies  we  have  found  that  there  is 
always  a  lymphatic  involvement,  and  that,  upon  freeing  the  lymph  flow 
the  symptoms  disappear.  This  stateinent  may  be  new.  I  have  not 
seen  it  discussed  elsewhere,  but  if  you  will  work  on  lymphatic  drainage 
technique  in  these  two  troubles,  you  will  soon  find  that  the  lymph  flow 
that  has  been  checked  for  a  period  of  time  has  much  to  do  with  the  un- 
pleasant symptoms  that  are  associated  with  it. 

Secure  good  venous  drainage  and  then  work  to  the  end  of  reducing 
the  nodes  by  treatment  around  the  base  of  the  neck. 

We  will  take  up  intercostal  lymph  drainage  in  the  next  section. 
The  pectoral  lymph  vessels  anastomose  with  the  intercostals  at  some 
points,  but  axillary  drainage  does  not  include  intercostal  drainage  to 
any  great  extent. 

Intercostal  Lymphatics 

The  intercostal  area  is  extensive.  The  combined  length  of  the 
intercostal  arteries  and  veins  would  measure  possibly  72  feet.  The 
lymphatic  vessels  have  nodes  principally  at  the  sternal  and  vertebral  ends. 
A  few  nodes  may  be  found  in  the  intercostal  spaces.  The  posterior  nodes 
of  the  intercostal  lymphatic  chain  lie  near  the  heads  of  the  ribs  and  re- 
ceive the  afferents  from  the  intercostal  spaces  and  muscles.  The  upper 
five  or  six  nodes  have  eflferents  leading  to  the  subclavian  veins  in  the 
two  main  ducts.  The  lower  six  nodes  have  efferents  leading  to  the  be- 
ginning of  the  thoracic  duct  near  the  receptaculum  chyli.  Thus  the 
drainage  of  the  posterior  and  lateral  sections  of  the  intercostals  is  partly 
upward  and  partly  downward,  and  then  upward.  The  right  lymphatic 
duct  receives  only  the  efferents  of  the  upper  six  intercostals  in  the  pos- 
terior region  on  that  side,  and  the  thoracic  duct  the  upper  six  left  at  its 
terminal  into  the  subclavian  vein  and  the  lower  six,  right  and  left  into 
the  beginning  of  the  thoracic  duct. 

About  eighteen  intercostal  efferents  of  the  posterior  thoracic  region 
enter  the  thoracic  duct  at  some  point  and  only  six  the  right  lymphatic 
duct. 

The  anterior  intercostal  drainage  lymph  vessels  are  in  relation  to 
the  internal  mammary  blood  vessels.  The  internal  mammary  nodes 
collect  and  carry  lymph  by  efferents  to  the  subclavian  veins.  They 
collect  from  the  thorax,  mammary  gland,  upper  surface  of  the  liver,  the 
diaphragm,  internal  intercostal  muscles,  and  subpleural  tissue. 

So  we  have  two  systems  of  drainage  of  lymph  in  the  intercostal 
region,  and  two  chains  of  nodes,  one  on  front  of  ribs  near  costovertebral 


Thorax  79 

union,  and  one  behind  sternal  end  of  ribs  in  relation  to  internal  mammary 
blood  vessels.  The  two  chains  on  either  side  of  the  sternum  in  the  an- 
terior  region  have  efferents  from  their  nodes  to  the  subclavian  veins. 
Each  side  draining  into  the  vein  on  each  side  as  compared  with  the  pos- 
terior lymph  drainage  of  three  fourths  into  thoracic  duct  and  one  fourth 
in  right  lymphatic  duct. 

The  nodes  found  behind  the  sternum  at  the  lowest  point  collect 
from  the  diaphragm  and  the  upper  surface  of  the  liver  and  pleural  sur- 
face in  that  area.  It  is  through  the  ana^itomoses  of  these  two  anterior 
chains  and  their  collection  from  the  outer  mammary  region  that  infec- 
tion may  cross  from  one  side  to  the  other  in  malignant  breast  cases.  It  is 
also  through  the  lower  collection  of  lymph  back  of  the  ribs  in  the  sternal 
end  that  diseases  of  the  lungs  and  liver  may  be  conveyed  from  one 
organ  to  another.  The  lymph  vessels  from  the  parietal  pleura  enter 
these  nodes.  The  many  lesions  that  may  interfere  with  intercostal 
lymph  drainage  hinge  principally  on  the  lack  of  normality  of  the  spine. 
Single  or  group  lesions  of  the  ribs  will  interfere  with  lymph  drainage. 
The  first  rib  may  cause  more  disturbance  than  any  other,  as  it  is  in  re- 
lation to  the  subclavian  vessels  and  these  veins  receive  the  terminal 
drainage  of  all  the  lymph. 

So,  we  will  start  at  the  top;  first,  we  will  detect  any  subluxation 
through  scaleni  tension  or  through  costovertebral  tension.  Next  the 
upper  thoracic  vertebrae  to  determine  existing  lesions,  three  vertebrae 
usually,  at  least.  A  single  vertebra  is  seldom  in  lesion  without  disturb- 
ing the  one  above  and  the  one  below.  The  intercostal  nodes  near  heads 
of  ribs  may  be  enlarged  through  the  state  of  the  tissues  suppHed  by  the 
intercostal  blood  vessels,  through  lesioned  ribs,  or  vertebrae.  These 
nodes  are  usually  independent  of  communication  with  the  mediastinal 
nodes  and  vessels.  Thej^  simply  drain  the  lymph  from  the  intercostal 
spaces  and  convey  it  to  the  subclavian  veins.  The  internal  mammary 
nodes  receive  the  lymph  vessels  of  the  pleura  in  that  region  and  connect 
with  lymph  vessels  of  the  diaphragm  and  the  upper  surface  of  the  liver. 
These  last  nodes  and  efferents  may  eventually  join  the  tracheobronchial 
and  anterior  mediastinal  to  form  the  bronchomediastinal  that  empty 
into  the  subclavian  vein  directly,  or  into  the  large  ducts  on  either  side. 

The  second  rib  may  also  be  lesioned,  by  contraction  of  the  attached 
scalenus  muscle,  or  by  a  vertebral  lesion.  This  rib,  with  the  first,  forms 
the  uppermost  intercostal  space. 

The  lymph  flow  will  be  interfered  with  if  there  is  undue  intercostal 
tension,  as  by  separation  of  the  two  ribs  through  stress  or  lesion,  and 
lymph  blockage  may  occur  if  the  ribs  are  approximated  through  vertebral 


80  Lymphatics 

lesions  or  costal  subluxations.  The  postero-lateral  intercostal  lymph 
vessels  follow  the  blood  vessels,  as  is  the  rule  elsewhere,  and  the  lymph 
drainage  may  be  interfered  with,  secondarily,  by  the  blood  supply  being 
checked,  or  through  venous  stasis  by  lack  of  vascular  drainage. 

So  we  might  go  on,  rib  by  rib,  and  discuss  each  intercostal  space, 
but  sufl&ce  it  is  to  say  that  single  rib  lesions  may  cause  a  greater  propor- 
tionate disturbance  than  group  lesions  where  there  is  an  extended  scoli- 
osis of  gradual  development. 

In  any  instance,  however,  we  are  interested  in  the  lymph  flow, 
and  especially  the  efferents  that  convey  the  terminal  drainage.  The 
thoracic  nerves  are  nourished  by  a  regulated  blood  supply.  The  lymph 
enters  into  the  drainage  of  the  tissues  and  the  channels  must  be  kept 
clear  if  we  wish  tone  in  tissues  supplied  with  blood. 

Faulty  posture  and  a  drooped  chest  will  not  only  affect  the  inter- 
costal venous  and  lymph  drainage  but  may  block  the  veins  and  lym- 
phatics of  the  organs  both  in  the  chest  and  below  the  diaphragm.  We 
cannot  have  a  blockage  at  any  point  between  the  terminal  lymph  ducts 
and  a  more  remote  area  without  a  checking  of  the  lymph  flow  beyond 
the  point  of  blockage.  The  proposition  is  similar  to  that  of  the  blood 
stream.  Impaired  intercostal  drainage  will  prevent  hepatic,  pleural  and 
diaphragmatic  lymph  flow. 

In  fairly  normal  conditions  the  interference  with  lymph  flow  at  any 
point  may  not  mean  systemic  disturbance,  but  if  there  exists  inflamma- 
tion as  is  found  in  certain  organs  and  coverings  when  certain  diseases 
are  present,  we  find  the  collateral  anastomotic  lymph  vessels  convey- 
ing and  spreading  the  toxic  products,  and  in  malignant  cases  regurgita- 
tion in  some  instances,  as  referred  to  in  another  section. 

In  certain  dissections  we  have  observed  nodes  more  numerous  than 
found  in  bodies  where  no  malignant  conditions  exist.  In  the  epigas- 
tric region  especially  the  blockage  in  the  venous  tissues  and  the  resultant 
thickened  tissue,  through  congestion  and  toxic  deposit,  there  are  num- 
erous small  nodes  and  disturbed  lymph  aff'erent  and  efferent  vessels, 
which  allow  a  more  widely  spread  toxic  condition. 

The  lack  of  rib  movement  in  certain  cases  where  the  spinal  and 
costal  muscles  are  almost  rigid  through  colds  or  lesions  or  even  organic 
reflex  irritation,  all  point  to  a  checking  up  of  the  lymph  flow  in  the  in- 
tercostal vessels  and  nodes;  also  in  the  trunks  leading  to  the  subclavian 
vessels.  There  must  be  freedom  of  chest  movement,  as  mentioned  by 
Dr.  Bush  in  her  chapter  on  exercises,  if  we  may  expect  free  lymph  flow 
in  the  afferents.  There  must  also  be  motion  in  every  thoracic  articula- 
tion to  insure  intercostal  lymph  and  blood  flow. 


Thoeax  81 

The  vasomotors  that  control  the  intercostal  arteries  have  an  in- 
direct influence  on  the  lymph  flow.  The  better  the  blood  circulation 
in  both  arteries  and  veins,  the  more  normal  will  be  the  lymph  flow.  A 
subluxated  rib  may  affect  the  lymph  flow  sufficiently  to  cause  poisoning  of 
the  tissues  around  a  nerve.  Thus  we  see  in  herpes  a  breaking  out  on 
the  skin  due  to  a  lesion  affecting  the  nerve  and  its  sheath. 

In  almost  every  instance  an  osseous  lesion  will  cause  a  lymph  dis- 
order as  well  as  vascular  irregularities  and  nerve  instability.  The  lymph 
spaces  are  almost  everywhere  and  they  must  be  reckoned  with  if  we  wish 
healthy  tissues.  Wherever  there  is  muscle  rigidity  or  tension  we  will 
find  the  lymph  spaces  and  vessels  more  or  less  blocked  by  undue  tension 
and  altered  vascularization. 

The  lymph  flow  must  move  onward  just  the  same  as  the  venous 
blood,  or  there  will  be  pathological  changes  as  a  result  of  the  inactivity. 
The  lymph  passes  through  nodes  continuously  in  a  normal  tissue  con- 
dition. The  checking  of  this  flow  through  any  of  the  causes  that  in- 
terfere  with  the  nodes'  activities,  or  of  the  lymph  vessels'  conveying 
properties,  will  mean  a  changed  lymph  substance.  If  the  nodes  collect 
and  retain  lymph  laden  with  toxic  productss,  uppuration  will  result. 
Should  this  occur  in  the  bronchial  nodes,  there  is  danger  of  tubercular 
infection  in  the  lung  tissue  from  the  broken  down  nodes  that  lie  along 
the  branches  of  the  bronchial  tubes. 

If  the  nodes  in  the  mammary  gland  become  enlarged  and  indurated 
and  then  malignant,  through  adjacent  tissue  and  duct  poisoning,  there 
is  danger  of  spreading  of  this  substance  through  the  lymph  vessels.  The 
lymph  must  be  conveyed  to  the  subclavian  veins  without  nodular  re- 
tardation to  be  good  lymph.  The  moment  there  is  a  checking  of  the 
lymph  flow  in  the  vessels  or  nodes,  that  moment  the  lymph  is  altered  in 
its  consistency.  The  influence  on  the  immediate  tissues  surrounding  a 
blocked  lymph  node  may  be  observed  in  palpable  areas,  and  if  there  is 
continued  blockage  and  nodular  enlargement,  the  other  nodes  and  ves- 
sels may  cause  the  disorder  to  become  a  systemic  one  instead  of  local. 

The  whole  system  of  lymphatics  may  become  altered  eventually, 
through  a  primary  pathological  area  in  which  there  has  been  retained 
toxins  followed  by  suppuration. 

Lymphatics  of  the   Heart  and  Pericardium 

The  relation  of  the  heart  to  the  trachea  allows  lymph  drainage  of 
both  to  readily  enter  the  tracheobronchial  nodes.  The  plexus  of  lymph 
vessels  in  the  endocardium  communicate  freely  with  the  plexus  found 
inside   the   visceral   pericardium.     The   efferents   follow   the   coronary 


82  Lymphatics 

vessels  in  the  grooves  on  the  surface  of  the  heart  and  the  right  and  left 
vessels  pass  backward  in  relation  to  the  pulmonary  artery  to  reach  the 
trachea  and  bronchi. 

The  lymphatic  drainage  of  the  heart  is  worthy  of  special  considera- 
tion. Here  we  have  an  organ  in  a  class  by  itself;  a  moving  organ,  pul- 
sating and  pumping  blood  all  over  the  body  after  receiving  it,  with  valves 
opening  and  then  closing.  The  lymph  vessels  are  moving  also  with  the 
heart  in  motion,  and  they  are  also  influenced  by  the  constant  contraction 
and  relaxation  of  the  cardiac  muscle.  Possibly  nowhere  in  the  body 
do  we  find  a  better  lymph  flow  than  in  the  heart,  and  its  covering,  the 
pericardium.  The  absence  of  nodes  is  explained  by  the  active  drainage 
through  the  efferents.  Nodes  are  practically  unnecessary,  and  if  pres- 
ent might,  in  certain  cardiac  disorders,  cause  undue  pressure  and  dis- 
turbance to  an  organ  that  is  sensitive  to  pressure  or  stress.  The  lymph 
spaces  between  the  bundles  of  cardiac  muscles  in  the  connective  tissue 
communicate  with  the  vessels  in  the  endocardium  and  epicardium.  Thus 
we  have  normally  a  perfect  drainage  of  lymph  from  the  heart  to  the 
nodes  on  the  trachea  and  its  divisions.  It  is  through  a  blockage  of  the 
tracheobronchial  nodes  that  we  find  interference  with  the  Ijonph  flow 
in  and  around  the  heart.  In  tubercular  conditions  of  the  lungs,  when 
there  are  enlarged  tracheobronchial  nodes  and  suppuration,  a  sec- 
ondary effect  upon  the  heart  is  noticed.  The  cardiac  efferents  no  longer 
drain  the  lymph  freely  into  the  nodes  and  terminal  efferents.  There  is 
a  tendencj'^  toward  coronary  vessel  thickening  and  hardening.  In  an- 
gina we  find  the  lymph  drainage  has  been  checked  and  a  deposit  formed 
that  is  due  to  continued  lymph  blockage.  Again  we  find  the  cardiac 
nerves  affected  by  lymph  blockage  and  node  enlargement  in  the  areas 
where  the  nodes  are  adjacent  to  the  cardiac  nerve  trunks.  The  cervical 
cardiac  sjrmpathetics  as  well  as  those  coming  from  the  pneumogastric 
may  be  compressed  by  poor  lymph  drainage  in  the  cervical  nodes  and 
vessels.  There  may  be  an  edematous  condition  of  the  tissues  in  the 
neck  and  throat  due  to  lymph  blockage  that  will  reflect  upon  the  tone 
of  the  cardiac  nerves.  Likewise,  a  thickening  of  the  tissues  around  the 
trachea  and  bronchi  may  cause  pressure  that  will  reflect  itself  upon  the 
base  of  the  heart  and  thp  supei-ficial  and  deep  cardiac  plexuses.  The 
lesions  that  cause  vasomotor  instability  of  the  coronary  arteries  and 
l)lood  vessels  leaving  the  heart,  pulmonic  and  systemic,  may  influence 
the  lymphatics  in  the  walls  and  around  the  heart.  The  blood  supply 
to  the  various  cardiac  nerves  and  plexuses  may  cause  a  change  in  the 
lymph  spaces  which,  in  time,  will  produce  a  slight  cardiac  variation  of 
rhythm.     This  has  not  been  accounted  for  in  the  various  treatises  on 


Thorax  83 

heart  diseases,  but  we  have  found  that  the  lymphatic  system  plays  a 
goodly  part  in  the  rhythmic  action  of  the  heart.  In  one  case  treated 
some  months  ago,  when  an  accelerated  cardiac  action  existed,  we  noted 
a  lymph  blockage  and  nodular  enlargement  in  the  cervical  region  accom- 
panied by  edema  in  the  supraclavicular  area.  Desirous  of  regulating 
the  heart's  action  by  a  better  lymphatic  drainage,  we  worked  to  that  end. 
Reduction  of  cervical  nodes  and  a  better  drainage  of  the  efferents  from 
the  tracheobronchial  nodes  brought  about  a  more  normal  heart  action 
in  a  very  short  time.  We  assumed  that  the  lymph  spaces  were  more  or 
less  blocked  in  the  cardiac  muscle  tissue  and  poisoning  or  irritation  had 
existed  through  lack  of  free  drainage  of  the  lymph  in  the  right  and  left 
trunks  that  go  to  the  tracheobronchial  nodes.  The  lymph  had  been 
retained  too  long,  and  the  effect  upon  the  cardiac  muscle  was  obsei-ved. 
The  cervical  area  also  had  its  influence  on  the  cardiac  nerves  through 
lymph  inactivity,  and  the  edematous  area  above  the  clavicles  aided  the 
blocking  of  the  lymph  flow  from  the  lower  nodes  and  efferents. 

In  cases  of  goitre  we  also  have  noted  that  a  part  of  the  cardiac  varia- 
tion  from  normal  was  due  to  Ijinph  blockage  in  the  region  of  the  thy- 
roid vessels.  Pressure  of  the  gland  also  affected  the  nerves.  Interfer- 
ence with  the  blood  supply  of  the  heart  and  pericardium  affects  the 
lymph  stream  in  the  grooves  containing  the  blood  and  lymph  vessels. 

Too  little  attention  has  been  paid  to  the  lymphatic  consideration 
in  relation  to  heart  action.  Hardening  of  the  coronary  arteries  is  a 
lymph  proposition  to  a  great  extent,  and  the  primary  lymph  blockage 
may- be  at  a  distant  point.  The  effect  of  costal  and  vertebral  lesions 
on  the  flow  of  lymph  has  been  discussed  in  another  section,  but  we  wish 
to  emphasize  again  the  importance  of  free  lymph  drainage  through  the 
correction  of  lesions  that  will  block  the  IjTnph  flow  from  the  tracheal 
region  and  cardiac  efferents.  Very  little  lymph  flow  interference  in  the 
auricles  and  ventricles  will  in  time  cause  a  cardiac  fluctuation  from  nor- 
mal. We  may  look  for  this  in  cases  where  there  is  bronchitis  and  nodu- 
lar enlargement  above  the  clavicles. 

Lymphatics  of  the  Esophagus 

This  tube  is  of  sufficient  length  to  have  at  least  two  collecting  sys- 
tems of  lymph  vessels.  We  find  the  network  of  lymphatics  in  the  mus- 
cular coat  collected  by  the  submucous.  They  collect  from  the  lymph 
spaces  in  the  mucous  tissues  and  in  the  lower  part  of  the  esophagus  the 
drainage  is  toward  the  nodes  in  the  coeliac  region.  In  the  upper  part 
of  the  esophagus  the  posterior  mediastinal  nodes  receive  the  afferents 
and  convey  the  lymph    by    efferents    to    the  subclavian  veins.     The 


84  Lymphatics 

esophagus  is  drained  then  by  nodes  that  lie  adjacent  to  the  tube.  The 
flow  of  lymph  depends  chiefly  upon  the  normal  activity  of  these  adjacent 
nodes.  The  lower  drainage  will  depend  upon  the  patency  of  the  thor- 
acic duct  that  indirectly  receives  the  lymph  vessels  from  the  esophagus. 
It  is  the  upper  drainage  that  is  the  more  important  as  all  of  the  lymph 
must  eventually  reach  the  thoracic  duct  and  subclavian  vein  in  some 
way. 

Should  there  be  bronchial  affection  and  enlarged  nodules  in  the 
posterior  mediastinal  area,  the  lymph  checking  will  be  reflected  upon 
the  drainage  of  the  esophagus.  The  vasomotor  control  of  the  blood 
vessels  to  the  esophagus  will  indirectly  act  upon  the  lymph  vessels. 

Lesions  that  cause  a  vascular  irregularity  in  the  esophageal  tissues 
will  block  the  lymph  spaces  and  cause  retarding  of  lymph  that  will  pro- 
duce a  change  in  not  only  the  mucous  tissues  but  in  the  lymph  fluid. 
Retardation  of  lymph  in  the  lymph  spaces  for  any  period  will  cause 
changes  that  in  time  will  interfere  with  the  normal  action  of  this  tube. 

The  nodes  that  collect  the  lymph  from  the  esophagus  also  collect 
the  lymph  from  the  diaphragm,  upper  surface  of  the  liver,  and  sometimes 
a  part  of  the  pericardium. 

The  extent  of  lymph  interference  then  may  be  reflected  upon  sev- 
eral membranes  as  well  as  the  esophagus.  It  is  impossible  to  check  the 
lymph  flow  in  certain  nodes  without  affecting  in  some  regions  several 
diff"erent  organs  or  membranous  coverings. 

The  esophagus  may  be  constricted  through  lesions,  and;^,when  this 
condition  is  present  we  also  find  a  lymph  space  obstruction , which  re- 
acts and  makes  the  altered  change  more  marked. 

The  esophagus  passes  through  the  diaphragm  and  we  may  find 
there  at  times,  through  costal  lesions,  an  altered  flow. 

In  gastroptosis  the  esophagus  is  extended  suflSciently  at  times  to 
affect  the  lymph  in  the  spaces  of  its  mucous  and  muscular  tissues.  The 
absence  of  nodes  within  the  esophageal  tissues  throws  the  burden  on 
the  collecting  nodes  in  adjacent  areas.  The  terminal  drainage  points 
must  receive  the  most  consideration. 


CHAPTER  FIVE 

LYMPHATICS  OF  THE  ABDOMEN  AND  PELVIC 

REGION 

Lymphatics  of  the  Diaphragm 

While  there  is  a  free  anastomosis  between  the  plexuses  of  lymph 
vessels  on  the  thoracic  and  abdominal  surfaces  of  the  diaphragm,  yet 
the  drainage  vessels  collect  from  above  and  below.  The  diaphragm 
occupying  a  dome  shaped  area  of  considerable  extent  empties  its  lymph 
on  the  thoracic  surface  into  the  lymph  nodes  that  lie  in  the  various  ad- 
jacent  regions.  The  pleural  sac  contains  lymph  vessels  that  communi- 
cate freelj^  with  those  of  the  thoracic  surface  of  the  diaphragm.  The 
lymph  vessels  are  more  numerous  at  the  points  of  contact  of  the  pleura 
and  diaphragm. 

Thus  the  lymph  vessels  in  the  region  of  the  aorta,  where  it  passes 
in  relation  to  the  diaphragm,  enter  these  nodes,  while  the  esophageal  nodes 
collect  from  a  more  central  portion,  and  the  sternal  nodes  from  the  an- 
terior  vessels.  Two  of  the  three  areas  mentioned  contain  nodes  that 
join  or  help  to  form  the  mediastinal  drainage  system.  The  drainage  of 
the  thoracic  surface  of  the  diaphragm  will  depend  upon  the  normal 
functioning  of  the  nodes  on  the  aorta  and  esophagus  first,  and  upon  the 
mediastinal  nodes  second,  before  the  final  efferents  enter  the  subclavian 
veins.  The  anterior  area  is  drained  by  the  nodes  behind  the  sternum 
and  costal  cartilages.  These  nodes  give  afferents  to  the  internal  mam- 
mary chain  of  nodes  that  follow  the  course  of  the  internal  mammary 
artery.  We  see  then  that  a  portion  of  the  thoracic  lymph  drainage  of 
the  diaphragm  is  collected  by  the  lymph  vessels  and  nodes  lying  behind 
the  sternal  ends  of  the  ribs  and  a  portion  is  collected  by  the  mediastinal 
nodes  that  lie  in  relation  to  the  aorta  and  posterior  mediastinal  glands. 

The  attachment  of  the  outer  border  of  this  drum-head-like  muscle 
membrane  suggests  the  possibility  of  costal  lesions  affecting  its  vascular 
and  lymph  drainage.  The  nerves  to  the  diaphragm  are  given  off  high 
up,  in  the  cervical  region,  and  lesions  in  that  area  maj^  disturb  its  inner- 
vation. The  most  probable  and  most  likely  disturbance  of  the  lymph 
flow  in  the  diaphragm  is  through  the  lymph  vessels  in  the  pleura  and 
liver. 

The  presence  of  septic  conditions  in  the  pleura  will  affect  the  IjTnph 
stream  in  the  diaphragm.  The  portion  of  the  pleura  adjacent  to  the 
diaphragm  is  drained  by  common  efferents.     While  this  is  only  a  small 

—85— 


86  Lymphatics 

portion  of  the  pleura,  yet  .we  find  in  septic  conditions  a  great  amount  of 
lymph  blockage  and  nodular  enlargement. 

The  correction  of  costal  lesions  and  the  regulation  of  the  circula- 
tion will  clear  the  lymph  stream  unless  there  is  a  great  amount  of  septic 
poisoning.  The  abdominal  surface  of  the  diaphragm  on  the  right  side 
is  in  contact  with  the  liver  and  the  communicating  lymph  vessels  are 
numerous. 

The  subperitoneal  tissue  vessels  also  anastomose  at  the  periphery 
of  the  diaphragm  with  its  lymph  vessels.  Here  we  may  again  have 
septic  infection  through  the  lymph  vessels  that  anastomose  so  freely. 
The  aortic  nodes  collect  the  lymph  on  the  right  side.  There  are  also  a 
few  nodes  on  the  inferior  phrenic  artery. 

The  esophageal  nodes,  also  aortic,  collect  lymph  from  the  diaphragm 
on  the  left  side.  The  esophageal  nodes  are  near  the  stomach  end  of 
the  tube.  The  aortic  nodes  are  to  the  side  and  in  front  of  the  artery. 
These  nodes  have  efferents  leading  directly  or  indirectly  into  the  recep- 
taculum  chyli  or  lower  portion  of  the  thoracic  duct. 

The  liver  if  diseased  will  reflect  its  disorder  upon  the  lymph  vessels 
and  nodes  that  drain  the  diaphragm.  Thus  we  see  the  diaphragm  lies 
in  a  position  that  allows  of  septic  infection  through  the  pleura,  dia- 
phragm and  subperitoneal  tissue. 

Unless  there  is  a  malignant  condition  in  the  adjacent  organs  and 
tissues  the  lymph  flow  can  be  regulated  through  correction  of  lesions 
and  the  re-establishing  of  lymph  and  blood  flow.  If  there  is  malignancy 
it  is  better  to  not  attempt  drainage. 

Lymphatics  of  the  Liver 

As  pointed  out  in  the  lymph  drainage  of  the  lungs  and  pleura,  also 
of  the  diaphragm,  the  collecting  lymph  vessels  drain  areas  according 
to  the  portion  of  the  organ  or  tissue  that  is  approximate.  The  liver, 
having  a  great  surface  and  occupying  a  position  that  for  convenience  sake 
we  will  call  horizontal,  necessarily  must  have  a  lymph  drainage  that 
will  be  divided  into  parts  corresponding  with  the  mediastinal  divisions. 
To  make  it  simple  to  the  student,  we  will  state  again  that  lymph  drain- 
age usually  follows  lines  of  least  resistance,  so  to  speak,  and  that  place 
is  along  the  course  of  vessels  or  of  tubes.  The  hepatic  veins  lead  to  the 
inferior  vena  cava  and  we  find  the  lymph  vessels  from  the  posterior  sur- 
face, both  deep  and  superficial,  follow  along  this  path.  These  collecting 
vessels  pass  to  the  nodes  around  the  uppermost  part  of  the  inferior  vena 
cava  and  communicate  with  the  posterior  mediastinal  nodes.  You 
will  remember  the  short  terminal  distance  the  vena  cava  has  after  re- 


Abdomen  and  Pelvic  Region 


87 


Plate  XVIII.  The  terminal  drainage  of  the  liver  through  the  three-fold 
channels. — (1)  Internal  mammary  chain.  (2)  Mediastinal  lymph  drain- 
age. (3)  Nodes  near  inferior  vena  cava.  (4)  Thoracic  duct.  (,5  &  6) 
Lymph  channels  from  nodes  back  of  ensiform  cartilage.  (7)  Receptacu- 
lum  chvli. 


88  Lymphatics 

ceiving  the  hepatic  veins,  also  the  relation  of  the  vena  cava  to  the  pos- 
terior mediastinum.  The  convex  surface  of  the  liver  that  is  in  relation 
to  the  diaphragm  has  at  a  few  places  lymph  vessels  common  to  both  and 
we  find  the  nodes  on  the  anterior  superior  surface  of  the  diaphragm  be- 
hind  the  ensiform  cartilage  collecting  lymph  for  the  internal  mammary 
nodes. 

The  under  surface  of  the  liver  and  the  bile  ducts  have  lymph  vessels 
that  pass  to  the  hepatic  nodes  and  pericardial  nodes  of  a  chain  that 
supplies  the  gastric  lymph  area.  The  lymph  vessels  in  the  esophageal 
opening  of  the  diaphragm  convey  lymph  from  portions  of  the  liver  in 
that  region  to  the  gastric  chain  of  nodes.  These  are  also  in  communi- 
cation with  the  lymph  vessels  of  the  pancreas.  Thus,  we  have  the 
lymph  vessels  passing  along  the  hepatic  veins  to  nodes  on  the  vena  cava 
inferior,  others  passing  through  the  diaphragm  in  esophageal  opening, 
and  still  others  traversing  the  diaphragm  near  the  front  to  enter  the 
anterior  mediastinal  nodes  that  form  a  part  of  the  internal  mammary 
chain. 

The  lymph  from  the  under  surface  of  liver  is  collected  by  tributaries 
of  the  receptaculum  chyli  directly  or  indirectly.  These  latter  vessels 
follow  the  hepatic  artery,  bile  ducts,  portal  vein,  and  through  the  he- 
patic nodes.  This  arrangement  makes  the  lymph  drainage  simple  to 
understand;  the  hepatic  veins,  inferior  vena  cava,  esophagus,  hepatic 
artery,  bile  ducts  and  portal  vein  are  all  followed  by  lymph  drainage 
vessels.  The  lymph  vessels  pass  through  the  diaphragm  at  three  points. 
The  inferior  vena  cava  opening,  the  esophageal  opening  and  direct 
traversing  of  the  diaphragm  at  the  anterior  portion  to  reach  the  nodes 
behind  the  ensiform  cartilage. 

This  three-fold  system  of  lymph  drainage  has  various  points  of 
termination.  The  lymph  vessels  that  follow  the  hepatic  veins  and  in- 
ferior vena  cava  are  received  by  nodes  that  are  in  the  chain  of  the  pos- 
terior mediastinal  node  group.  These  nodes  have  terminals  in  the  right 
lymphatic  duct  unless,  as  sometimes  is  the  case,  they  have  separate 
terminals  in  the  subclavian  vein.  The  second  drainage  point  is  through 
the  internal  mammary  nodes  that  have  final  efferents  into  the  subclavian 
vein  or  the  larger  right  lymphatic  duct;  the  third  drainage  vessels  are 
those  that  are  collected  in  the  receptaculum  and  its  tributaries  to  be 
conveyed  by  the  thoracic  duct. 

To  summarize  the  drainage:  there  are,  first,  the  right  posterior 
mediastinal;  second,  the  right  internal  mammary  chain;  and  third,  the 
thoracic  duct  collecting  lymph  from  the  liver  through  hepatic,  gastric 
and  pancreatico-duodenal  nodes  in  the  region  of  the  receptaculum  chyli. 


Abdomen  and  Pelvic  Region 


89 


Plate  XIX.     Lymphatics  of  the  surface  of  the  Hver, 


90  Lymphatics 

In  diseases  of  the  liver  we  have  then  three  different  sets  of  lymph 
vessels  conveying  toxic  or  possibly  septic  products.  The  internal  mam- 
mary chain  of  nodes  may  be  blocked  or  enlarged.  This  will  interfere 
with  the  collecting  of  lymph  from  the  anterior  intercostals  and  the  inner 
surface  of  the  breast,  as  well  as  from  the  deeper  areas  of  the  anterior 
thoracic  wall  which  includes  the  portion  of  the  pleura  in  that  region. 

The  posterior  mediastinal  nodes  receive  lymph  that  has  followed 
along  the  lymph  vessels  in  relation  to  the  hepatic  veins,  and  inferior 
vena  cava.  Should  there  be  an  enlarged  condition  of  these  nodes  through 
lung  affection,  or  from  any  congestion  or  infection  of  the  various  tissues 
and  organs  drained  by  these  nodes,  we  will  find  the  liver  flow  checked. 
This  may  cause  other  lymph  vessels  in  the  liver  to  take  up  in  part  the 
work  of  lymph  drainage. 

The  third  drainage  point  is  through  the  thoracic  duct  and  here  we 
may  find  the  greatest  amount  of  blockage.  The  hepatic  nodes,  the 
gastric  nodes,  and  the  pancreatico-duodenal  nodes  receive  and  convey 
to  the  thoracic  duct  a  large  part  of  the  liver's  lymph.  In  gastric  dis- 
orders, not  necessarily  malignant,  we  may  look  for  enlarged  nodes,  also 
in  disturbances  of  the  pancreas.  There  may  be  lymph  blockage  from  a 
gastro-duodenal  ulcer.     All  these  maj""  reflect  upon  hepatic  drainage. 

The  lymph  vessels  of  the  liver  are  numerous  and  are  divided  into 
the  superficial  and  deep,  but  they  all  pass  through  the  three  sets  of 
terminals  outlined  above.  Eventually  they  reach  the  subclavian  veins. 
In  malignancy  the  liver  may  convey  septic  products  through  any  of 
these  three  separate  channels.  The  puffiness  above  the  clavicles,  includ- 
ing involvement  of  the  supraclavicular  nodes,  mentioned  by  Osier,  as 
occurring  through  the  internal  mammary  chain,  is  not  as  likely  to  oc- 
cur as  in  the  more  direct  involvement  through  the  other  two  drainage 
systems.  The  posterior  mediastinal  collect  hepatic  lymph  more  direct 
than  does  the  internal  mammar\'  chain  and  the  vessels  are  from  a  deeper 
portion  of  the  liver.  These  mediastinal  nodes  send  efferents  that  have 
a  terminal  similar  to  that  of  the  internal  mammary  chain  of  nodes  and 
the  involvement  of  the  supraclavicular  nodes  of  the  former  is  much 
more  likely.  The  thoracic  duct  drainage  of  the  liver  lymph  is  less  direct 
as  the  lymph  must  pass  through  various  nodes  before  l^eing  received  by 
the  thoracic  duct. 

There  is  a  lessened  chance  of  liver  malignancy  if  we  keep  the  lymph 
drainage  free.  We  have  pointed  out  elsewhere  that  the  liver  is  the 
chief  organ  in  systemic  pollution — that  in  the  majority  of  cases  the  liver 
is  involved  primarily  and  the  other  organs  are  affected  secondarily. 
If  the  lymph  drainage  of  the  liver  is  blocked  it  is  only  a  short  time  be- 


Abdomen  and  Pelvic  Region  91 

fore  some  other  organ  will  take  on  a  diseased  condition.  The  three 
drainage  sj^stoms  from  the  liver  include  the  three  systems  that  also  drain 
the  major  portion  of  the  body's  lymph. 

The  right  mammary  chain  of  nodes  collects  the  lymph  of  the  liver 
from  a  small  area  only.  The  left  mammaiy  chain  may  receive  part 
of  this  as  the  two  chains  are  connected  by  lymph  vessels,  but  Osier  re- 
fers to  the  involvement  of  supraclavicular  nodes  on  the  left  side  in  par- 
ticular. We  find  the  right  side  is  the  important  one  as  the  right  chain 
conveys  most  of  the  lymph  from  the  anterior  diaphragmatic  nodes 
through  the  nodes  back  of  the  ensiform  cartilage. 

The  right  broncho-mediastinal  trunk  likewise  collects  some  lymph 
from  the  convex  surface  of  the  liver.  Very  little  lymph  from  the  con- 
vex surface  of  the  liver  reaches  the  left  subclavian. 

The  liver  has  so  many  vessels  and  ducts  that  the  lymph  stream  is 
well  conveyed,  but  at  the  same  time,  there  is  no  organ  that  blocks  itself 
quicker  than  the  liver.  The  many  functions  of  the  liver  and  the  receiv- 
ing of  the  portal  vein  with  its  vast  distribution  and  the  hepatic  veins 
collecting  and  emptying  into  the  vena  cava,  along  with  the  biliary  ducts 
carrying  bile  into  the  duodenum,  gives  us  an  insight  into  the  lymph 
vessel  blockage  that  may  occur  if  this  organ  becomes  diseased.  The 
hepatic  artery  supplying  the  liver  has  vasomotor  regulation  and  indi- 
rectly the  hnnph  stream  is  augmented  by  the  normal  tone  of  the  artery 
and  its  branches.  The  better  the  blood  circulation  the  better  the  lymph 
flow.  Thoracic  lesions  that  interfere  with  the  blood  flow  to  the  liver 
will  cause  a  h'mph  retardation  through  the  organ.  Lesions  that  inter- 
fere with  the  lymph  vessels  and  nodes  between  the  liver  and  the  sub- 
clavian veins  must  be  corrected  if  we  expect  good  lymph  drainage.  The 
left  subclavian  collects  the  major  part  of  the  liver's  lymph;  the  right 
lymphatic  trunk  only  part  from  its  convex  and  po.5teriof  surface. 

We  must  look  to  the  left  postclavicular  area  for  thoracic  duct  drain- 
age. Cervical  lesions,  first  rib,  or  clavicular  subluxations  may  have  a 
bearing  on  the  liver's  lymph  drainage.  We  usually  think  that  we  re- 
duce an  enlarged  liver  or  restore  its  various  functions  to  normal  by  the 
correction  of  thoracic  lesions  at  the  nerve  centres  to  the  liver,  but  we 
must  not  overlook  the  Ij^mph  drainage  which  has  its  terminals  through 
three  difTerent  courses  before  it  reaches  the  subclavian  veins. 

Lymphatics  of   the  Stomach  and  Intestines 

In  the  cardiac  lymphatic  system  we  spoke  of  the  lymph  flow  being 
accelerated  by  a  constant  moving  of  the  lymph  vessels  located  in  an 
organ  that  is  beating  almost  continuously.     In  the  stomach  we  have 


92  Lymphatics 

lymph  vessels  in  and  on  the  walls  of  an  organ  that  has  a  churning  move- 
ment and  is  capable  of  great  expansion  through  its  contents  as  well  as 
by  the  presence  of  gases.  The  stomach  has  a  goodly  number  of  nodes 
lying  between  the  folds  of  the  omenta,  as  well  as  being  distributed  around 
the  cardiac  end  of  the  stomach,  the  pericardial,  also  the  pyloric  end, 
the  subpyloric. 

The  mucous  membrane  lymph  vessels  pass  to  the  sub-mucous. 
Collecting  trunks  pierce  the  muscular  coat  in  the  lesser  and  greater 
curvatures  and  these  afferents  are  received  by  the  gastric  chain.  Ef- 
ferents  from  the  gastric  enter  the  preaortic  nodes  of  the  coeliac  group 
to  enter  the  receptaculum  chyli  as  separate  trunks  or  as  the  combined 
channel  known  as  the  intestinal  lymphatic  trunk. 

After  all,  the  lymph  drainage  of  the  stomach  as  well  as  of  the  spleen 
and  pancreas  eventually  is  collected  by  the  coeliac  group  of  nodes  which 
lie  in  front  of  the  aorta  in  relation  to  the  coeliac  axis.  The  main 
lymph  nodes  and  vessels,  as  in  the  other  organs,  lie  along  the  course  of 
the  blood  vessels.  The  lymph  drainage  of  the  stomach  is  such  that 
certain  areas  are  drained  quite  independently  of  others.  This  is  of 
value  when  there  is  a  pyloric  diseased  condition,  the  fundus  of  the 
stomach  may  not  be  blocked  or  involved.  The  splenic  nodes  receive  a 
part  of  the  stomach's  lymph  along  the  splenic  artery.  Again  we  will 
note,  as  in  cancer  of  the  breast  and  other  organic  infectious  areas,  there 
may  be  a  regurgitation  of  lymph. 

In  treating  the  stomach  for  a  better  lymph  flow,  we  will  find  it 
necessary  to  work  with  the  view  of,  first,  a  free  thoracic  duct  drainage 
by  keeping  the  terminal  clear  in  the  clavicular  region,  and  second,  by  a 
free  lymph  flow  in  the  coeliac  region. 

The  vasomotor  control  of  the  gastric  blood  vessels  will  help  to  clear 
the  lymph  vessels  and  nodes.  Should  there  be  lesions  that  cause  gastric 
atony  we  will  expect  lymph  retardation. 

Gastroptosis  will  prevent  gastric  lymph  vessel  efferents  from  clear- 
ing  the  lymph  spaces.  As  the  lymph  vessels  of  the  stomach  have  a 
common  duct  drainage  with  the  spleen,  pancreas,  and  mesenteric  area, 
in  some  instances  we  must  try  and  determine  the  amount  of  blockage 
that  already  exists  when  there  is  stasis  or  ptosis  of  the  abdominal  viscera. 
The  receptaculum  chyli  is  quite  protected  by  the  abdominal  aorta  and 
if  no  aneurism  exists  or  thickened  tissues  in  this  region  the  most  import- 
ant  lymph  area  to  note  will  be  that  of  the  preaortic  nodes.  The  reduc- 
tion of  lesioned  areas  that  control  the  blood  vessels  that  supply  and 
drain  the  gastric  area  is  of  primary  importance.     On  first  thought,  the 


Plate  XX.  Lymphatics  of  the  Stomach. — (1)  Cervical  node.  (2)  Tracheal  nodes, 
(3)  Thoracic  duct.  (4)  Mediastinal  efferents.  (5)  Bronchial  nodes.  (6)  Aortic 
nodes.  (7)  Esophageal  Ijanphatic  vessels.  (8)  Left  Pericardial  nodes.  (9) 
Right  Pericardial  nodes.  (10)  Right  gastro-epiploic  nodes.  (11)  Gastric  and 
pancreatic  nodes.     (12)  Subpyloric  nodes. 


94  Lymphatics 

student  may  picture  the  receptaculum  chyli  as  lying  in  front  of  the  aorta 
and  subject  to  gastric  pressure  and  even  contact,  but  we  will  remember 
the  relation  of  the  aorta  to  the  receptaculum  chyli  and  note  that  it  is 
the  ducts  leading  to  it  that  are  subject  to  compression  and  blockage. 
The  diaphragm  may  be  drawn  unduly  by  cervical,  lesion  affecting 
phrenics,  and  by  lumbar  or  costal  lesions,  and  this  may  affect  the  lymph 
flow  to  some  extent.  The  thoracic  duct  follows  along  the  aorta  in  its 
relation  to  the  diaphragm,  but  lies  in  a  position  that  is  more  subject  to 
vertebral  lesions.  The  great  proposition  in  abdominal  lymph  drainage 
is  one  of  stasis  and  ptosis.  The  entire  alimentary  tract  may  have  a 
ptosic  expression,  a  general  visceroptosis. 

About  90%  of  white  people  are  constipated.  The  vast  majority 
are  slaves  to  laxatives.  Some  take  oil,  others  anything  from  senna 
to  salts.  It  is  easy  to  reason  out  the  effect  constipation  has  on  the  lym- 
phatics. The  great  receptaculum  chyli  with  its  numerous  tributaries  is 
in  a  constant  state  of  over  taxation.  Ptosis  and  venous  stasis  are  in- 
evitable. The  lymph  vessels  and  nodes  in  the  mesentery  are  chron- 
ically enlarged  and  overburdened.  The  dragging  down  of  the  trans- 
verse colon,  including  the  hepatic  and  splenic  flexures,  interfere  with 
the  drainage  of  the  lymph  in  the  reservoir.  Auto-intoxication  includes 
lymph  retardation.  Toxic  accumulation  is  obvious  when  ptosis  or 
stasis  is  present. 

Splanchnoptosis  is  one  of  the  vital  causes  of  lymph  blockage.  The 
vasomotor  control  of  the  abdominal  viscera  normally  is  possibly  one 
of  the  best  arranged  systems  in  the  body. 

The  vasomotor  nerves  in  the  visceral  vessels  are  more  elaborate 
than  found  elsewhere.  The  preganglionic  fibres  are  longer  and  are  not 
supplanted  by  the  postganglionic  fibres  until  the  solar  plexus  is  reached. 
This  gives  unusual  tone  to  the  vessels  given  off  from  the  abdominal 
aorta.  But  ptosis  alters  this  normal  condition  and  we  find  not  only  a 
lack  of  tone  in  the  vasomotors,  but  a  faulty  innervation  impulse  in  the 
peristaltic  arrangement  and  control.  The  sagging  of  the  bowels  pro- 
duces stress  upon  vessels,  nerves  and  lymph  channels. 

No  organ  or  tissue  remains  nonnal  where  there  is  an  altered  posi- 
tion  in  the  respective  regions.  Perfect  tone  is  found  where  vasculariza- 
tion and  innervation  remains  unimpaired.  If  the  intestines  are  sagged 
out  of  normal  line  the  mesentery  is  likewise  malpositioned  and  the  lymph 
vessels  are  not  free  to  carry  away  their  load  of  lymph. 

There  is  only  one  method  of  correcting  stasis  and  ptosis,  and,  thanks 
to  the  osteopathic  technique,  we  may  by  adjustment  relieve  the  stress 
and  restore  the  sagging  viscera.     We  find  the  spinal  column  a  container 


Abdomen  and  Pelvic  Region 


95 


Platk  XXI.  lATuph  drainage  of  the  caecum  and  appendix.  Thp  ileo- 
caoca!,  anterior  caecal  nodes  and  vessels  arc  phown,  also  the  node  of  the 
appendix. 


96  Lymphatics 

of  these  nerve  impulse  centers  that  control  not  only  the  circulation  but 
the  nerve  tore  and  vermicular  action  of  the  alimentarj'^  tract.  We  must 
look  to  the  correction  of  lesions  and  scoliotic  conditions  for  a  remedy  in 
abdominal  disturbances. 

First  we  must  correct  innominate  lesions,  if  they  exist,  as  it  is  use- 
less to  attempt  spinal  correction  with  the  expectancy  of  permanent 
results  without  first  having  the  foundation  of  the  spine  in  perfect  align- 
ment. The  sacrum  must  be  true  to  its  axis  in  relation  with  the  innomi- 
nates.  A  tilt  of  the  sacrum  may  be  detected  when  least  expected.  The 
limbs  must  be  of  equal  length,  unless  a  previous  break  or  faulty  mal- 
nutrition has  shortened  one.  Perfect  alignment  of  osseous  tissue  firet 
is  necessarj'. 

Various  vertebral  and  lower  costal  lesions,  so  often  found  in  ptosis, 
must  be  corrected  as  nearly  as  it  is  possible  before  we  may  expect  a  free 
flow  of  lymph.  The  region  of  the  diaphragm  is  also  very  important. 
An  enlarged  liver,  spleen  or  pancreas  with  gastroptosis  must  command 
consideration  before  we  attempt  to  secure  a  normalization  of  the  trans- 
verse colon. 

In  order  to  reach  the  innervation  and  vasomotor  control  of  the  or- 
gans and  tissues  that  are  within  the  region  of  the  diaphragm  we  must 
need  look  higher  up  for  costal  and  vertebral  lesions.  This  reverts 
to  the  statement  that  the  entire  framework  must  be  in  perfect 
alignment. 

Just  recently  I  assisted  in  an  autopsy  which  gave  me  additional 
data.  The  case  was  of  peculiar  interest  as  I  knew  the  subject  had  been 
given  serum  treatment  for  a  duodenal  growth.  We  spent  some  time 
in  this  post  mortem  and  I  examined  with  care  the  state  of  the  lymphatics. 
Each  organ  below  the  diaphragm  was  overhauled  to  determine  the  amount 
of  lymphatic  involvement.  It  was  almost  beyond  comprehension.  I 
never  knew  so  many  nodes  existed.  Every  node  seemed  enlarged  and 
indurated.  The  jaundiced  condition  due  to  duct  blockage,  and  the 
gastric  outlet  almost  beyond  recognition  was  surrounded  by  a  lym- 
phatic enlargement  and  nodular  retention  that  had  defied  correction. 

Just  today  I  examined  a  woman  with  hepatic  congestion  and  biliary 
obstruction  that  showed,  on  palpation,  the  abnormal  condition  of  the 
lymph  glands. 

If  one  is  sufficiently  interested  in  lymphatics  to  carefully  palpates 
in  everj'  accessable  region,  it  is  astonishing  how  the  condition  of  the 
nodes  will  index  the  patient's  complications. 

We  have  called  attention  to  the  fact  that  no  organs  containing  lym- 
phatics  can  be  involved  without  a  corresponding  lymphatic    disorder. 


Abdomen  and  Pelvic  Region 


97 


Plate  XXII.— The  Ij-mphatic  node?,  in  some  regions,  not  only  contain 
vasomotor  nerves  but  have  definite  nene  plexuses.  The  mesenteric 
nodes  lie  in  rela+ion  to  the  vessels  and  are  more  numerous  in  diseased 
visceral  areas  than  i.'s  commonly  thought.  The  vasomotor  arrangement 
of  the  mesenteric  arteries  is  shown  in  relation  to  the  cord  and  sympa- 
thetic nerve  chain. 


98  Lymphatics 

We  may  not  bo  able  to  palpate  the  lymphatics  in  all  abdominal  organs, 
but  in  many  instances  we  can  learn  to  detect  enlarged  nodes  or  lymphatic 
blockage. 

In  a  measure  we  can  estimate  the  amount  of  lymph  blockage  by 
the  degree  of  ptosis.  We  can  also  determine  to  a  certain  extent  the 
lymphatic  involvement  by  the  torsion  in  the  duodenum  when  gastroptosis 
exists. 

The  question  of  lymph  regurgitation  in  gastric  trouble  is  verified 
in  operations  for  duodenal  and  pyloric  constrictions. 

The  relation  of  the  kidneys  and  suprarenals  to  the  cisterna  chyli 
is  also  significant.  The  pancreas,  with  its  peculiar  position  and  relation 
to  the  stomach  and  duodenum,  gives  us  an  insight  into  the  lymphatic 
disturbances  found  in  gastric  malpositions. 

We  have  a  lot  to  learn  yet  as  to  the  real  part  played  by  the  lym- 
phatics in  their  relation  to  the  ductless  glands,  but  we  have  come  to 
believe  the  physiological  chemistry  of  the  body  is  dependent  upon  the 
state  of  the  lymph.  Faulty  metabolism  must  include  a  blocked  lym- 
phatic system  at  some  point  at  least.  The  restoration  to  health  de- 
pends upon  the  degree  of  Ijrmphatic  vessel  tone  and  freedom  from  ob- 
struction. 

The  nerve  centers  that  control  the  abdominal  lymphatics  corre- 
spond in  a  measure  to  those  of  the  vasomotors  to  the  abdominal  blood 
vessels.  Perfect  alignment  of  osseous  tissue  and  reduction  of  organic 
congestion  will  clear  the  lymph  vessels  if  ptosic  conditions  are  remedied, 
unless  there  is  malignant  trouble.  Recently  I  examined  a  woman  of 
53  who  complained  of  gastric  disorders.  Upon  thorough  examination 
I  discovered  a  growth  in  the  region  of  the  duodenum.  X-ray  confirmed 
the  diagnosis.  The  case  was  a  typical  one  of  lymphatic  engorgement. 
The  giowth  suggested  malignancy.  Upon  reconsideration  I  decided 
to  pass  the  case  up.  The  involvement  was  too  great  and  if  malignancy 
existed  it  seemed  too  great  a  risk  to  overstimulate  the  lymphatics.  This 
case  was  an  extraordinary  one  and  in  her  atonic  condition  I  felt  justified 
in  not  attempting  what  might  prove  a  fruitless  task.  It  seems  wise 
sometimes  to  give  in  to  doubt  rather  than  to  face  a  defeat  later  and  be 
accused  of  spreading  the  toxins. 

There  is  a  limit  to  the  clearance  of  lymphatic  blockage  and  it  is 
well  to  know  when  to  halt.  An  overtaxed  system  with  constitutional 
disorders  of  numerous  phases  may  not  be  cleared  even  by  the  most  dex- 
terous adjustment  and  correction.  The  lymphatics  are  sometimes  so 
badly  complicated  that  to  attempt  to  clear  them  may  mean  adding  fuel 
to  the  fire.     I  have  admitted  this  point  just  to  show  how  I  feel  in  these 


Abdomen  and  Pelvic  Region  99 

severe  cases.  But  the  ordinary  eases,  where  no  indication  of  malignancy 
is  present,  justify  us  in  attempting  at  least  to  clear  the  circulation  and 
lymphatic   glands   of  their  load. 

In  this  age  when  cancer  is  so  prevalent  it  is  well  to  be  on  constant 
guard  to  detect  growths  or  conditions  that  indicate  an  incurable  phase. 
We  are  laboring  to  clarify  in  our  minds  as  nearly  as  possible  the  state  of 
the  abdominal  viscera  in  their  various  relations  to  the  benign  and  ma- 
lignant classifications.  This  may  not  be  possible,  but  we  can  come  nearer 
to  it  by  study  and  research. 

The  lymph  drainage  of  the  appendix  is  of  particular  value.  There 
is  usually  at  least  a  node  which  collects  the  lymph  from  the  afferent 
vessels.  We  have  found  that  in  appendicitis  there  is  an  enlargement  of 
the  inguinal  nodes  of  that  side.  This  may  be  accounted  for  in  two  ways. 
First,  there  is  sufficient  lymph  blockage  in  this  region  to  cause  enlarge- 
ment of  the  cecal  nodes.  The  mesenteric  nodes  are  also  enlarged  and 
through  the  tissue  congestion  and  venous  stasis  the  lymph  stream  is 
checked  by  an  overtaxed  drainage  centre,  the  beginning  of  the  thoracic 
duct.  This  reflects  upon  the  emptying  of  the  lymph  from  the  inguinal 
region  and  there  is  a  blocking  and  enlargement  of  the  inguinal  glands. 
This  may  be  noted  in  almost  every  instance  where  appendicitis  is  present. 
Second,  there  are  lymph  channels  in  the  inguinal  region  that  have  col- 
lecting tubes  from  around  the  appendix,  but  not  anastomosing.  These 
lymph  afferents  are  blocked  or  overloaded  through  congestion  and  dis- 
turbed vascularization  of  the  cecal  area.  If  pus  is  present  in  the  ap- 
pendix, the  inguinal  nodes  are  more  readily  palpable.  We  have  stated 
elsewhere  that  surgical  resort  may  be  determined  absolutely  by  the 
condition  of  the  right  inguinal  glands.  For  years  I  have  based  my  final 
diagnosis  in  operable  cases  on  this  finding.  After  all  other  tests  are 
made,  the  index  as  to  pus  finding  is  determined  by  the  palpation  of  these 
nodes. 

Lymphatics  of  the  Kidneys 

The  kidneys  lie  in  a  position  that  is  relative  to  the  beginning  of 
the  thoracic  duct.  The  lymphatic  vessels  follow  the  arteries,  as  usual, 
and  are  of  more  significance  than  usually  ascribed  to  them.  The  num- 
erous lymphatic  capillaries  in  the  medulla  and  cortex  have  an  influence 
on  the  tubules.  The  vascularization  of  the  kidney  substance  aids  the 
lymph  stream  in  that  there  are  more  definite  channels  than  found  in 
some  organs.  We  find  that  a  blockage  of  the  lymph  stream  in  the  re- 
gion of  the  nodes  that  receive  afferents  from  the  hver,  stomach  and  pan- 
creas reflects  itself  upon  the  lymph  stream  from  the  kidneys.    The 


100  Lymphatics 

blocking  of  preaortic  nodes  that  receive  lymph  vessels  from  the  kid- 
neys causes  a  blockage  of  the  lymph  in  the  cortex  and  medulla.  The 
effect  upon  the  kidneys  is  marked,  and  we  have  noted  that  in  certain 
kidney  disturbances  that  normal  functioning  did  not  return  until  the 
lymph  stream  was  cleared  and  allowed  free  drainage  from  the  deeper 
lymph  vessels.  Again  we  note  the  disturbance  of  the  lymph  flow  when 
there  is  faulty  innervation,  not  only  to  the  kidney  blood  vessels  but  to 
the  nerve  fibres  to  the  tubules.  The  lymph  stream  is  influenced  by  the 
nerve  supply  to  the  vessels  and  tubules  to  the  extent  of  causing  a  varia- 
tion in  the  flow  of  urine.  The  correction  of  lesions  that  have  caused 
instability  of  nerve  tone  brings  about  a  more  normal  flow  of  lymph,  and 
the  organ  functions  better.  A  lower  costal  lesion  may  cause  vascular 
and  lymph  irregularities  of  flow,  and  derange  the  finer  mechanism  in 
the  medulla  and  cortex  of  the  kidney.  Lower  thoracic  vertebral  lesions 
interfere  with  the  renal  plexus  of  nerves  and  in  this  way  bring  about 
variations  in  the  secretor>'  cells. 

We  have  noted  in  Bright's  disease  that  the  lymph  stream  was 
blocked  decidedly,  and  that  by  indirectly  influencing  the  lymph  chan- 
nels through  vasomotors  to  the  blood  vessels  the  change  in  the  tubules 
made  repair  quite  satisfactory.  Bright's  disease  is  to  a  great  extent  a 
lymphatic  disorder.  The  treatment  should  be  to  the  end  of  freeing  up 
the  efferent  lymph  channels  in  order  that  the  kidney  drainage  of  lymph 
may  be  more  complete.  The  collection  of  the  IjTnph  from  the  super- 
ficial vessels  is  of  less  importance.  The  channels  eventually  end  in 
the  nodes  around  the  aorta  and  the  lymph  is  collected  at  the  beginning 
of  the  thoracic  duct.  There  are  so  many  lymph  nodes  and  vessels  in 
this  small  area  that  it  is  reasonable  to  expect  an  overtaxed  condition 
of  the  nodes  if  there  exists  any  organic  disease  of  any  of  the  adjacent 
organs.  The  blockage  of  the  nodes  and  channels  from  the  stomach  or 
mesenteric  region  will  have  its  influence  upon  the  renal  lymphatics. 
Ptosis  of  the  stomach  will  also  have  a  bearing.  Correction  of  all  lesions 
to  this  area  will  relieve  the  kidneys  and  make  the  urine  more  normal 
in  color  and  quantity.  We  have  never  paid  sufficient  attention  to  the 
lymphatics  of  the  kidneys  in  the  various  diseases  of  these  organs.  While 
diabetes  is  a  constitutional  disturbance,  we  find  the  liver  and  kidneys  al- 
most invariably  taxed  and  the  renal  lymphatics  blocked.  If  you  apply 
specific  treatment  to  the  lymphatics  in  diabetes  you  will  get  good  re- 
sults. The  hepatic  nodes  and  renal  nodes,  as  well  as  the  mesentery, 
must  be  kept  free  from  blockage.  If  they  are  blocked  you  w411  soon 
see  it  reflected  upon  the  drainage  of  the  pelvis  and  even  the  inguinal 
and  popliteal  nodes.     The  lymph  drainage  below  the  kidneys  will  not 


Abdomen  and  Pelvic  Region 


101 


Plate  XXIII.     The  lymphatics  of  the  kidneys. 


102  Lymphatics 

be  normal  if  there  is  enlargement  of  the  nodes  and  blockage  in  the  lymph 
channels  in  the  region  of  the  receptaculum  chyli.  First  we  must  work  to 
secure  good  vasomotor  control  of  the  branches  of  the  abdominal  artery, 
also  the  corresponding  collecting  veins.  If  we  secure  this,  we  can  rea- 
sonably expect  an  effect  upon  the  lymph  drainage.  The  lymph  vessels 
follow  the  blood  vessels  so  closely  that  we  can  usually  aid  lymph  flow 
by  vasomotor  control  of  the  blood  vessels.  We  are  yet  to  determine 
just  how  extensively  vasomotor  fibres  are  scattered  over  the  lymph 
vessels  that  are  so  closely  associated  with  the  blood  vessels.  We  are 
inclined  to  believe  that  there  is  more  influence  brought  to  bear  than 
we  have  given  credit  for.  A  little  further  research  work  will  clear  this 
point.  We  are  also  yet  to  determine  just  how  much  lymph  is  collected 
in  the  veins  over  the  body  outside  of  the  subclavians.  As  mentioned 
elsewhere,  we  believe  that  in  time  we  shall  determine  that  the  entire 
venous  system  collects  lymph  at  numerous  intervals,  as  it  seems  in- 
credible that  the  entire  lymph  collection  of  the  body  should  be  con- 
fined to  the  two  veins  in  the  base  of  the  neck.  If  this  reasoning  is  true, 
it  will  account  for  the  clearing  up  of  the  lymph  stream  when  we  secure 
normal  vasomotor  control  of  the  blood  vessels.  The  close  relation  of 
the  lymph  vessels  and  nodes  to  the  veins  in  many  instances  allows  for 
collection  of  lymph  in  the  veins  at  various  points  in  minute  quantities. 
This  is  a  solution  to  the  problem  of  the  lymphatics  in  various  corditions 
where  there  is  a  lymph  blockage  and  an  edematous  condition. 

The  lymph  drainage  of  the  kidneys  is  most  important  in  any  and 
every  systemic  disturbance.  The  degree  of  normal  functioning  of  the 
kidneys  means  the  blocking  or  clearing  of  the  other  tissues  and  organs. 
Specific  treatment  to  increase  lymph  flow  in  the  vessels  leading  from  the 
kidneys  is  most  essential. 

The  internal  secretions  are  influenced  by  the  lymph  more  than  in 
any  other  way.  Every  organ  has  a  blood  supply,  and  along  the  vessels 
we  find  lymphatics  with  few  exceptions.  In  order  to  stabilize  the  body 
metabolism  we  must  secure  perfect  lymph  drainage.  This  will  allow 
ductless  glands  as  well  as  all  glands  and  tissues  to  put  forth  normal  se- 
cretions. The  nodes  must  be  kept  reduced  to  normal  size  and  the  lymph 
channels  free.  There  are  enough  palpable  glands  to  serve  as  an  index 
to  internal  systemic  disorders.  No  organ  or  ductless  gland  can  be  in- 
volved to  any  great  extent  without  reflecting  its  disturbance  and  block- 
age on  some  palpable  area.  We  must  look  for  edematous  areas.  There 
are  certain  areas  that  denote  specific  organic  lymph  blockage.  The 
watching  of  these  regions  that  are  prone  to  "puff"  is  very  essential. 
Learn  to  detect  "puffy"  areas.     They  may  exist  on  most  any  part  of 


Abdomen  and  Pelvic  Region  103 

the  bod}'.  There  may  be  zones  that  are  puffy  and  cool  to  the  hand. 
Trace  out  the  lymph  drainage  and  you  will  locate  the  organ  with  blocked 
lymphatics. 

If  the  kidney  lymph  drainage  nodes  are  blocked  you  may  find  a 
general  edema  over  the  kidneys  in  the  back,  or  it  may  be  reflected  on 
the  abdomen  over  the  beginning  of  the  thoracic  duct.  Next  go  above 
the  clavicles  and  note  any  edema,  and  by  comparing  the  three  areas 
you  can  pretty  well  decide  the  drainage  of  the  kidney  lymph.  If  there 
is  a  splanchnoptosis  present  it  will  be  necessary  first  of  all  to  correct 
lesions  that  will  allow  a  return  to  normal  position  of  the  viscera.  Gen- 
eral alignment  will  be  necessaiy  from  the  arches  of  the  feet  upward  to 
the  atlas.  General  vasomotor  tone  of  the  body  will  greatly  accelerate 
lymph  flow.  Specific  work  in  one  area  will  not  always  clear  the  trouble. 
The  lymphatic  system  must  be  considered  in  its  entirety,  and  we  must 
work  to  the  end  of  freeing  the  lymph  channels,  nodes  and  ducts  in  order 
to  reach  some  specific  organ  or  tissue. 

Lymphatics  of  the  Pelvic  Region 

The  organs  in  the  pelvic  basin  are  subject  to  great  stress  when  in- 
nominate lesions  exist,  and  such  lesions  are  not  uncommon.  Even  one 
innominate  in  lesion  will  draw  out  of  line  the  uterus  and  ovaries.  This 
unevenness  of  the  basins'  walls  causes  muscles  and  ligaments  attached 
to  the  innominate  bones  to  dr.aw  in  a  manner  that  blocks  the  blood  ves- 
sels and  lymph  channels.  Nodular  enlargement  follows,  and  a  con- 
gestion of  the  tissues  is  also  noticed.  If  allowed  to  remain  uncorrected, 
marked  symptoms  appear,  especially  at  the  menstrual  periods.  Cramps, 
retarded  flow,  and  sometimes  flooding  are  the  result,  depending  upon 
the  age  and  general  condition  of  the  patient. 

As  long  as  osseous  lesions  exist  there  will  be  blockage  of  blood  and 
lymph  vessels.  Careful  palpation  over  the  ovaries  will  reveal  the  change 
in  the  tissues.  The  effect  upon  the  lymphatics  in  the  legs  will  be  ap- 
parent. 1  here  may  be  a  slight  edematous  condition  around  the  ankles, 
and  the  popliteal  spaces  are  sure  to  record  the  blockage  that  is  present 
higher  up. 

If  the  kidneys  are  active  and  no  constipation  is  apparent  the  symp- 
toms are  minimized,  but  in  a  tilted  pelvis  there  is  almost  sure  to  be  con- 
stipation or  haemorrhoids.  There  is  stress  upon  all  the  muscles  attached 
to  the  pelvic  basin. 

The  lymphatic  arrangement  in  the  pelvic  organs  is  like  that  of  a 
great  net.  These  vessels  all  find  an  emptying  place  eventually  through 
one  tubet,  he  thoracic  duct.     This  duct  collects  from  all  points  below. 


104 


Lymphatics 


Plate  XXTV.     Lymphatics  in  relation  to  the  pelvis. 


Abdomen  and  Pelvic  Region  105 

The  uterine  and  ovarian  lymphatics  are  blocked  when  there  is  undue 
pelvic  congestion.  We  need  not  refer  to  venereal  diseases  and  their 
marked  effect  upon  the  lymphatics.  We  will  confine  this  article  to  pel- 
vic lymphatic  blockage,  through  lesions,  with  resulting  ptosis  and  nodu- 
lar enlargements. 

In  order  to  have  a  regulated  blood  supply  in  the  pelvic  organs  there 
must  be  good  vasomotor  tone  at  the  nerve  centers  that  control  the  blood 
vessels,  and  indirectly  the  h^mph  vessels.  Cervical  and  thoracic  lesions 
affect  vasomotor  control  clear  down  to  the  feet. 

To  relieve  pelvic  congestion  and  lymph  blockage  there  must  be  not 
only  adjustment  of  the  pelvic  bones  but  correction  of  all  lesions  up  to  the 
occiput.  A  scoliosis  will  disturb  the  ovarian  nerve  centre  even  though 
no  marked  innominate  lesion  exists.  First,  last  and  always  in  pelvic  con- 
gestion, we  must  secure  perfect  alignment.  It  is  so  easy  to  disturb  the 
pelvic  plexus  of  nerves  through  osseous  lesions,  and  there  is  a  tremendous 
reflex  following  pelvic  nerve  instability.  Splanchnoptosis  will  produce 
pelvic  lymph  blockage  in  any  and  every  instance.  The  lymph  vessels, 
when  there  is  no  abdominal  visceral  ptosis  and  vascular  stasis,  nor- 
mally clear  themselves  and  empty  into  tributaries  of  the  thoracic  duct, 
but  if  you  lesion  one  or  more  vertebrae  directly,  or  through  innominate 
or  sacral  tilts,  the  whole  arrangement  is  changed.  Nerve  impulses  are 
lessened,  lack  of  tone  is  noticed  and  a  congestion  or  inflammation  may 
be  the  result.  We  must  keep  the  organs  in  the  abdomen  in  their  proper 
tone  and  respective  regions  if  we  expect  to  have  normal  pelvic  organs. 
The  moment  there  is  venous  stasis  we  have  the  beginning  of  lymphatic 
blockage. 

Weakened  ligaments  allow  misplacements,  and  we  find  flexions 
and  versions  causing  nodular  enlargements.  Varicose  veins  and  edema 
follow  in  many  instances.  If  there  is  a  continued  lymph  blockage  in 
the  ovarian  and  uterine  regions,  leucorrhea  may  be  the  result  and  often 
is  very  persistent.  The  vascular  and  lymphatic  arrangement  is  peculiar 
in  the  pelvic  basin.  This  allowance  is  made  to  accommodate  the  changes 
during  pregnancy.  The  lymph  vessels  are  arranged  so  that  the  gravid 
uterus  will  not  obstruct  them  sufficiently  to  cause  white  swelling  under 
normal  conditions. 

Pelvic  and  vertebral  lesions  existing  before  and  during  pregnancy 
cause  many  symptoms  that  would  not  exist  had  the  lesions  been  cor- 
rected before  conception. 

Where  there  is  albumin  during  pregnancy,  we  find  the  lymph  nodes 
more  noticeable  and  the  lymph  drainage  down  the  leg  more  blocked 
than  in  a  normal  kidnev  condition. 


106 


Lymphatics 


I*i.ATE  XXV. — The  lymph  drainage  of  the  pelvic  regions  and  lower  extremity' 
IP  clearly  outlined.  In  ptosis  of  the  abdominal  viscera  the  lymph 
nodes  are  blocked  and  the  lymph  vessel?  drawn  downward  with  the 
viscera. 


Abdomen  and  Pelvic  Region  107 

Before  any  woman  contemplates  pregnancy  there  should  be  per- 
fect adjustments  made,  and  a  free  drainage  of  the  pelvic  lymphatics. 

The  presence  of  lacerations,  long  neglected,  are  causative  of  nodular 
enlargement.  The  absorption  of  secretions  and  discharges  reflect  the 
abrasion  upon  the  nodules.  This  may  produce  sufficient  nodular  en- 
largement and  lymph  blockage  to  cause  intrauterine  growths.  Any 
abrasion  is  followed  by  lymphatic  disturbance. 

In  cases  of  a  prolapsed  uterus  we  find  stress  upon  the  numerous 
lymph  vessels  and  nodes,  preventing  the  return  of  lymph  through  the 
tributaries  of  the  receptaculum  chyli.  Constipation  with  enlargement 
of  the  haemorrhoidal  veins  produces  a  nodular  enlargement  that  is  readily 
palpable  in  the  posterior  walls  of  vagina,  especially  back  of  the  cervix. 

A  lesioned  coccyx  will  cause,  through  pressure  and  traction,  a  series 
of  lymph  irregularities. 

During  the  menstrual  period  there  is  a  temporary  lymph  stasis 
and  you  will  notice,  sometimes,  the  inguinal  nodes  slightly  enlarged 
and  yet  quite  compressible  to  touch.  These  clear  up  shortly  after  the 
period. 

In  rheumatic  cases  we  find  the  most  general  disturbance.  The 
presence  of  uric  acid  with  possibly  a  mild  nephritis,  allows  the  careful 
palpator  to  observe  some  interesting  points. 

If  you  will  keep  the  lymphatics  in  mind  constantly  and  look  for 
nodular  variations  in  all  disorders  of  the  organs  and  tissues,  you  will  be 
surprised  in  time  to  note  a  peculiar  fluctuation  of  the  various  palpable 
nodes  in  the  accessible  regions. 

I  have  become  so  accustomed  to  palpating  nodes  that  I  invariably 
go  over  the  popliteal,  inguinal  and  axillary  regions,  just  to  satisfy  my- 
self that  the  lymphatic  system  fluctuates,  so  to  speak,  according  to  the 
chemistry  of  the  body. 

The  slightest  organic  disturbance  reflects  itself  upon  the  lymphatic 
system  at  some  point.  An  abcessed  tooth,  an  enlarged  tonsil,  a  bron- 
chial cough,  a  ptosis  or  stasis  in  the  mesentery,  a  pelvic  congestion  or, 
organic  prolapsis,  all  record  themselves  on  the  lymphatic  system  that 
becomes  blocked  so  readily  when  poisons  or  toxic  products  are  found 
within  the  system. 

Enlarged  lymph  nodes  are  a  true  index  of  some  pathological  phase 
at  some  point  within  the  body. 

There  is  a  communication  between  the  lymph  vessels  of  the  uterine 
area  and  the  superficial  inguinal  nodes.  This  allows  of  more  ready  palpa- 
tion of  the  inguinal  nodes  in  a  case  of  diseased  uterus.  The  majority  of 
the  lymph  vessels  of  the  uterine  walls  and  coverings  follow  along  the 


108  Lymphatics 

broad  ligaments.  The  aortic  nodes  eventually  collect  the  lymph.  The 
iliac  nodes  collect  from  the  coi-vix,  according  to  the  direction  of  the  various 
lymph  vessels  from  that  part.  The  vagina  is  lymph-drained  by  the 
nodes  that  lie  along  the  iliac  vessels  and  their  branches.  The  lymph 
drainage  from  the  bladder  is  separate  from  that  of  the  vaginal  region 
until  the  iliac  nodes  are  reached. 

On  the  sacrum  we  find  a  few  nodes  which  collect  with  the  mesen- 
teric nodes  the  lymph  from  the  muscular  coat  of  the  rectum.  The 
lymph  vessels  follow  the  course  of  the  haemorrhoidal  vessels  where  nodes 
are  distributed  that  send  efferents  to  the  mesenteric.  The  sacrum,  if 
tilted  in  relation  to  the  innominates,  may  disturb  these  lymph  nodes. 


CHAPTER  SIX 

VACCINES  AND   SERUMS   IN  RELATION  TO  THE 
LYMPHATIC  SYSTEM 

We  have  come  to  believe  that  the  most  effective  measure  in  proving 
the  harmful  results  of  vaccine  and  serum  poisonings  is  the  disturbance 
produced  in  the  h^mphatic  system  when  these  poisons  are  introduced 
into  the  circulation.  We  wish  to  go  on  record  as  being  opposed  to  the 
use  of  both  vaccines  and  serums.  As  osteopathic  physicians,  we  are 
taught  that  the  body  is  complete  within  itself,  that  there  are  within  the 
body  sufficient  secretions  to  combat  diseases  if  the  mechanism  is  properly 
adjusted.  We  believe  in  the  axiom  laid  down  by  the  founder  of  Oste- 
opathj',  that  the  "  rule  of  the  artery  is  supreme, "  etc.,  that  the  body  is 
a  perfectly  complete  chemical  laboratorj^  wherein  the  metabolism  is 
balanced  so  stably  that  health  is  maintained  when  we  are  lesion  free. 

The  lymphatic  system  plays  a  far  greater  part  in  the  body  mech- 
anism than  we  once  thought.  No  book  as  yet  has  been  published  deal- 
ing with  the  lymphatic  system  from  an  angle  other  than  merely  that  of 
an  anatomical  and  physiological  description.  The  new  method  of  diag- 
nosing various  diseases  by  palpation  of  lymphatic  nodules  is  yet  to  be 
accepted,  but  we  already  have  a  few  believers.  The  nodes  are  readily 
affected,  we  all  know,  when  poisons  are  introduced  into  the  system.  The 
mother  of  any  child  can  see  for  herself  the  effects  of  vaccine  poisoning  if 
she  will  but  look  for  them.  She  can  see  the  swollen  glands  in  the  neck 
and  armpit  following  a  vaccination  that  "takes."  No  one  need  have 
a  more  striking  demonstration. 

In  the  illustrations  shown  here  the  lymphatic  vessels  and  nodes 
are  outlined  on  the  figures  to  show  the  areas  most  commonly  affected. 

Observe  the  vaccination  sore  on  the  arm  lies  in  a  path  of  direct 
lymphatic  connection  with  the  glands  in  the  axilla.  These  axillary 
glands  enlarge,  and  it  is  with  difficulty  the  arm  is  raised.  In  a  few 
days  sore  throat  occurs  and  the  tonsils  enlarge.  Next  we  find  the 
neck  or  cervical  glands  enlarging  and  there  is  usually  a  complication 
continuing  of  blockage  and  nodular  enlargement  of  the  bronchial 
glands  as  shown  in  the  accompanying  plate, 

The  swelling  of  the  axillary  glands  blocks  the  drainage  down  the  arm 
and  in  severe  cases  the  adenitis  is  followed  by  the  arm  and  even  hand 
swelling.  Cases  of  gangrene,  erysipelas  and  cellulitis  are  recorded  by 
authorities  such  as  Osier,  Holt,  Peebles  and  others.     In  Higgins'  work  on 

—109— 


no 


Lymphatics 


Plate  XXVI. — Showing  the  possibility  of  incipient  phlhisis  through  lymphat- 
ic blockage,  as  the  result  of  vaccine  or  serum  poisoning  in  the  axillary 
region.  The  bronchial  glands  are  closely  related  to  tho«eof  the  cervical 
region. 


Vaccines  and  Serums  111 

the  ''Horrors  of  Vaccination"  repeated  cases  of  suppuration  of  the  lym- 
phatic glands  from  vaccination  are  recorded. 

Once  the  lymphatic  vessels  and  nodes  are  blocked,  there  is  a  sys- 
temic disturbance  that  involves  the  various  organs  of  the  body  and  many 
patients  state  that  their  breakdown  and  ill  health  dates  from  the  time 
of  vaccination,  or  the  poisoning  of  the  body  through  blockage  of  the 
lymphatics. 

Hundreds  of  persons  have  died  from  this  lymphatic  poisoning  fol- 
lowing vaccination.  It  is  a  question  whether  or  not  a  severe  vaccine 
poisoning  is  not  more  difficult  to  clear  than  a  venereal  poisoning.  The 
sores  following  suppuration,  after  vaccination,  are  almost  impossible 
to  heal  in  some  instances.  Arms  and  legs  have  been  either  disabled  or 
amputated  in  a  number  of  cases. 

In  the  normal  person  it  is  with  difficulty  the  lymphatic  system  is 
kept  clear.  There  are  sufficient  toxic  products  in  the  system  at  all  times 
to  tax  the  nodes  and  vessels.  To  inject  or  introduce  by  scratching  in 
a  virus  that  is  in  itself  a  polluted  product  is  to  endanger  the  body  in 
many  instances.  The  insidiousness  of  intravenous  injections  is  so 
marked  that  unless  a  person  is  naturally  immune,  he  takes  chances  of 
producing  an  adenitis. 

The  enlargement  of  the  axillary  glands  makes  it  possible  for  the 
lymphatic  vessels  to  convey  these  poisons  to  the  pectoral  or  breast  re- 
gion. The  lumps,  found  in  the  breast  of  a  girl  or  woman  after  vaccina- 
tion, are  hard  to  reduce  and  often  persist  for  years.  Who  knows  but 
that  these  lumps,  in  time,  cause  cancer? 

Numerous  cases  of  phthisis  have  been  recorded  following  vaccina- 
tion. The  bronchial  glands  enlarge  after  the  cervical  glands,  and  the 
blockage  soon  poisons  the  lung  tissue.  A  cough  results  and  the  first 
stage  of  consumption  is  recorded. 

When  vaccination  is  made  in  the  leg,  as  shown  in  the  plate,  there  is 
a  nodular  swelling  in  the  groin  or  inguinal  region.  As  these  glands  are 
connected  with  the  pelvic  lymphatics,  we  find  the  ovary  on  the  vacci- 
nated side  congested  and  sensitive.  In  some  cases  the  inguinal  adenitis 
is  so  marked,  the  patient  is  unable  to  work  for  days.  It  takes  time  to 
reduce  this  lymphatic  blockage  and  the  leg  is  often  swollen,  and  in  some 
instances  turns  black.  The  lymphatic  blockage  may  extend  down  to 
the  foot.     Suppuration  follows,  and  a  running  sore  persists  for  months. 

We  are  now  confronted  with  the  blockage  of  the  mesenteric  nodes 
and  interference  with  drainage  in  the  thoracic  duct.  The  plate  shows 
the  abdominal  nodes  and  the  duct  leading  up  to  the  neck.  Another  plate 
shows  the  lymphatics  of  the  pelvic  region. 


112 


Lymphatics 


Plate  XXVII. — Lymphatic  involvement  in  vaccination.  The  possibility 
of  nodular  enlargement  in  the  axillary  and  cervical  region?,  including 
the  tonsillary  area,  i?  plainly  shown.  The  lymphatics  of  the  entire 
arm  may  become  involved,  and  spread  to  the  pectoral  region. 


Vaccines  AND  Serums  113 

It  is  a  serious  proposition  to  block  the  already  taxed  lymphatic 
system.  If  the  receptaculum  chyli  is  blocked  practicallj^  all  the  ab- 
dominal organs  are  improperly  drained.  The  lymph  flow  is  as  essential 
as  the  blood  flow,  and  the  poisoning  of  the  lymphatic  system  simply  means 
the  poisoning  of  the  entire  body  tissues  and  organs. 

In  dealing  with  serums  we  have  a  blockage  or  poisoning  as  striking 
as  in  vaccine  pollution.  I  have  seen  cases  in  my  city  that  had  been 
given  serums  and  observed  a  breaking  out  on  the  body  of  ugly  boils 
and  sores.  A  number  of  cases  of  sudden  deaths  following  serum  in- 
jections were  recorded  this  year.  Two  cases,  well  known,  died  within  a 
few  minutes  after  the  serum  was  given.  Direct  poisoning,  more  sud- 
den than  poison  given  to  kill.  Instructions  were  given,  following  these 
sudden  deaths,  to  give  all  serum  injections  at  home  with  the  patient  in 
bed.  Is  it  possible  that  a  method  of  this  kind  is  scientific  or  necessary 
to  restore  health? 

One  case  in  my  city,  where  a  serum  was  given  for  acne,  resulted  in 
the  girl  being  taken  to  a  hospital  where  she  died  a  few  days  later.  As 
osteopaths,  we  believe  in  keeping  the  system  clear  and  the  arteries  car- 
rying pure  blood.  We  are  opposed,  as  a  body  of  physicians,  to  the 
pollution  of  the  blood  stream. 

A  most  striking  case  of  direct  lymphatic  poisoning  in  a  child 
came  to  my  notice  four  years  ago.  The  case  was  the  son  of  a  physi- 
cian, who  had  been  given  antitoxin  for  supposed  diphtheria.  The  nodular 
enlargement  of  the  cervical  glands  and  tonsils  was  so  great  that  the 
neck  was  almost  as  large  as  the  head.  It  was  with  great  difficulty  the 
child's  life  was  saved. 

To  have  a  vaccination  scar  is  a  reflection  on  the  high  intelligence  of 
a  civilized  people.  A  scar  following  a  solicited  vaccination  signifies 
loyalty  to  medical  superstition.  A  scar  from  forced  vaccination  is  a 
brand,  and  is  a  mark  of  medical  tyranny  and  despotism.  I  would  not 
be  vaccinated  and  take  the  risk  of  comphcations  for  a  $10,000  check. 
My  children  have  never  been  vaccinated  and  I  trust  never  will.  So 
many  mothers  are  frightened  when  an  epidemic  scare  is  on,  they  simply 
give  in  and  have  their  children  vaccinated  for  fear  they  might  be  kept 
away  from  school.  I  would  rather  keep  my  children  out  until  the  scare 
is  over,  than  to  submit  them  to  the  dangers  of  lymphatic  poisoning.  If 
mothers  of  the  land  would  take  a  determined  stand,  we  could  make 
compulsory  vaccination  a  thing  of  the  past  in  a  few  years. 

The  serum  theory,  presented  by  Medical  Doctors,  claiming  that 
it  is  a  scientific  treatment,  induces  adults  all  over  the  land  to  take  serums 
for  almost  every  complaint.     I  am  of  the  opinion  that  there  will  be  a  great 


114 


Lymphatics 


Plate  XX VIII. — We  find  that  vaccination  on  the  thigh  or  just  above  the  knee 
causes  enlargement  and  sometimes  suppiu^ation  of  the  inguinal  nodes.  As  the 
ovary  and  pelvic  regions  are  in  close  proximity,  sterility  may  result  where  poison- 
ing has  affected  the  glands  and  tissues  of  that  region. 


Vaccines  AND  Serums  115 

reaction  some  of  these  days,  and  just  as  the  best  specialists  are  not  per- 
forming  many  tonsillectomies,  so  the  best  physicians  will  not  long  give 
serums  for  every  complaint.  We  cannot  afford  to  block  the  system  un- 
duly.    We  want  instead  to  find  a  way  of  clearing  the  system  of  poisons. 

In  treating  the  lymphatics  we  must  work  with  one  point  in  view; 
that  of  freeing  the  lymphatic  channels  and  ducts  first  at  their  emptying 
})oint  in  the  neck,  and  then  clear  the  lymphatic  vessels  and  nodes  at 
distant  points.  First  the  thoracjc  area  and  then  the  abdominal  and  pel- 
vic areas.     The  extremities  come  last. 

The  lymphatic  vessels  and  nodes  must  be  reached  through  the  vaso- 
motor centers  that  control  them  directly  or  indirectly.  We  must  get 
combined  effect  on  the  vascular  system  and  lymphatics.  No  super- 
ficial treatment  will  be  of  any  great  value.  We  must  reach  the  deeper 
or  main  vessels  and  ducts.  The  intercostals  may  be  reached  by  thoracic 
adjustment,  and  the  receptaculum  chyli  and  its  tributaries  by  the  splanch- 
nic and  mesenteric  vasomotors.  .  If  you  clear  the  lymphatic  system  you 
will  clear  the  vascular  at  the  same  time. 

Six  swollen  lymphatic  glands  in  certain  areas  will  make  one  ill. 
A  dozen  will  put  you  on  your  back,  and  fifty  vital  glands  blocked  may 
cause  death. 

Let  us  work  together  as  osteopaths  to  clear  the  system  of  poisons, 
and  tell  the  people  of  th^  dangers  of  vaccines  and  serums. 


VACCINATION  AND  THE  LYMPHATICS 

C.  C.  Reid,  M.  D.,  D.  O.,  Denver,  Colorado 

Vaccination  as  a  method  of  preventing  smallpox  has  been  uni- 
versally adopted  by  the  medical  profession.  There  are  very  few  who 
openly  oppose  it.  Those  who  do  oppose  it  as  a  rule  keep  very  quiet  for 
fear  of  coming  under  professional  disapprobation.  There  arc  not  many 
people  who  have  the  "guts"  to  stand  up  against  public  sentiment  and 
the  general  professional  trend. 

Not  many  physicians  now  dare  to  speak  out  in  open  meeting  against 
the  universal  trend  toward  state  medicine.  Yet,  not  many  years  past 
we  had  the  autocracy  of  state  religion  which  required  many  years  and 
much  suffering  to  throw  off.  We  seem  now  to  be  ready  to  put  on  state 
medicine,  which  will  probably  be  more  galling  than  state  religion,  after 
it  is  thoroughly  estabhshed. 

During  the  last  smallpox  epidemic  and  the  resulting  scare,  a  very 
large  percentage  of  the  people  rushed  to  be  vaccinated.     Personally, 


116  Lymphatics 

I  have  no  way  to  prove  or  disprove  the  theory  of  vaccination.  Since  it 
has  been  adopted  ahnost  universally  by  the  medical  profession  and 
through  their  educational  propaganda,  vaccination  has  been  accepted 
largely  by  humanity  as  a  prevention  of  smallpox  and  people  desire  to 
have  it  done. 

Recently  I  had  occasion  to  vaccinate  many  of  my  patrons.  I  was 
interested  in  watching  the  results  of  the  vaccination  on  a  great  many  of 
them  whom  it  was  my  opportunity  to  observe.  Some  were  vaccinated 
on  the  arm  and  others  on  the  leg.  In  the  arm  cases,  where  it  took,  there 
was  an  enlargement  and  swelling  of  the  lymphatic  glands  in  the  axilla 
Those  that  took  on  the  leg,  showed  a  soreness  and  thickening  of  the 
gland  in  the  groin  on  the  side  of  the  vaccinated  leg. 

Many  of  them  had  large  pustules;  were  quite  sick  with  fever,  rang- 
ing from  101  to  103,  went  to  bed  for  from  one  to  three  days,  and  were 
more  or  less  prostrated  for  something  near  a  week. 

For  this  article,  the  interesting  phenomenon  was  the  effect  on  the 
lymphatic  glands.  You  might  turn  it  the  other  way  and  say  the  effect 
of  the  lymphatic  glands  on  the  vaccination.  The  functioning  of  the 
lymph  glands  showed  that  there  was  a  real  poisoning  or  infection  of 
that  part  of  the  body  on  which  the  vaccination  was  taking.  The  ten- 
dency of  that  infection  was  to  spread  through  the  system.  The  func- 
tion of  the  lymph  was  to  counteract  poison  and  head  off  infection. 

The  lymphatic  glands  in  the  groin  on  the  side  vaccinated  had  an 
extremely  hard  proposition  to  prevent  the  infection  from  spreading  in 
some  instances  throughout  the  system.  In  these  cases  if  it  were  not 
for  the  lymph  keeping  the  gateway  closed  against  a  large  per  cent,  of  the 
infection,  the  system  receiving  the  whole  bolt  at  once  would  very  likely 
be  overwhelmed. 

I  have  not  had  a  chance  to  observe,  but  I  believe  a  woman  who 
has  had  her  breast  removed,  along  with  which  the  axillary  glands  are 
frequently  removed  in  such  operations,  if  she  were  vaccinated  on  that 
side  afterward,  the  consequences  of  the  vaccination  on  her  system  would 
be  considerably  more  serious  as  a  result  of  the  absence  of  the  lymphatic 
glands.  Also,  in  cases  where  the  glands  of  the  axilla  have  been  removed 
the  patient  would  likely  suffer  more  in  a  systemic  way  when  vaccinated 
on  the  leg. 

Most  of  these  cases  had  a  real  acute  adenitis,  as  shown  by  the  en- 
largement and  swelling,  soreness  in  the  limb,  and  the  pain  in  the  glands 
of  the  axilla  or  the  groin,  according  to  the  location  of  the  vaccination. 
The  tonsils  and  the  lymphoid  tissue  making  up  Waldeyer's  ring  about 
the  throat  have  the  same  function  very  largely  as  that  of  the  lymphatic 


Vaccines  and  Serums 


117 


Plaie  XXIX. 
Enlarged  nodes  as  result  of  vaccination. 


118  Lymphatics 

glands.  When  there  is  a  toxin  or  infection,  as  there  frequently  is  in 
the  nose  and  throat,  some  portion  of  Waldeyer's  ring  becomes  thickened, 
enlarged  and  sore.  If  the  reaction  is  so  great  as  to  set  up  an  acute  con- 
dition, there  will  be  pain,  redness  and  swelling  sometimes  extending 
from  the  tonsils  into  the  tissues  of  the  neck  and  involving  practicalh^ 
the  whole  of  Waldeyer's  ring.  Repeated  inflammation  of  this  kind 
causes  enlargement  of  the  faucial  tonsils  and  the  pharyngeal  tonsils  known 
as  adenoids. 

Operations  in  this  region  of  course  should  be  conservative  because 
of  the  tendency  to  destroy  the  integrity  of  Waldeyer's  ring.  Every 
evidence  points  to  the  fact  that  the  structures  composing  this  ring  are 
placed  about  the  throat  for  a  protection  against  infections  and  toxins 
in  this  region. 

It  was  noted  that  many  of  the  patients  developed  sore  throat  with 
more  or  less  swelling  about  Waldeyer's  ring.  Those  who  had  tonsils 
showed  more  or  less  enlargement  there.  Those  who  did  not  have  ton- 
sils were  not  exempt  from  the  sore  throat.  The  effect  of  the  vaccination 
upon  the  lymphatics  was  to  cause  acute  inflammation  resulting  in  more 
or  less  chronic  conditions  causing  the  overworking  of  the  lymph  glands. 


EDWIN  MARTIN  DOWNING,  D.  O. 
York,  Pa. 


CHAPTER  SEVEN 

THE  ORIGIN  AND  FUNCTION  OF  THE  LYMPHATIC 

SYSTEM 

Edwin  Martin  Downing,  D.  O.,  York,  Pa. 

"Let  us  go  deeper  into  the  study  of  the  Hfe-saving  powers  of  the 
lymphatics." 

"Possibly  less  is  known  of  the  lymphatics  than  of  any  other  division 
of  the  life-sustaining  machinery  of  man." 

"We  lay  much  stress  on  the  uses  of  blood  and  the  powers  of  the 
nerves,  but  have  we  any  evidence  that  they  are  of  more  vital  importance 
than  the  lymphatics?  If  not,  let  us  halt  at  this  universal  system  of 
irrigation,  and  study  its  great  uses  in  sustaining  animal  life. " 

These  quotations  from  "The  Philosophy  and  Mechanical  Prin- 
ciples of  Osteopathy"  are  given  to  show  the  importance  in  Dr.  Still's 
mind  of  a  thorough  understanding  of  lymph  and  the  lymphatic  system. 
Those  who  have  followed  his  teachings  and  writings  know  that  Dr.  Still 
always  urged  this  point. 

Any  considerable  attention  to  the  subject  will  show  the  need  of  an 
intimate  knowledge  of  the  origin,  properties  and  movements  of  the 
lymph,  of  the  structure  of  the  lymph  vessels  and  glands,  and  of  the  re- 
lation of  the  entire  lymphatic  system  (including  the  lacteals)  to  the  me- 
tabolic processes  and  the  general  economy  of  the  body.     - 

Importance  of  The  Lymphatics 

In  support  of  this  statement  I  submit  the  following  propositions: 

1.  All  of  the  processes  of  tissue  nutrition  and  repair  are  dependent 
upon  the  lymph. 

2.  Since  the  blood  does  not  come  into  direct  contact  with  the  tissue 
cells  (except  in  one  organ — the  spleen),  one  of  the  main  functions  of 
blood  circulation  is  to  supply  and  renew  the  lymph  to  all  tissues.  As 
has  been  tersely  said,  "the  blood  feeds  the  lymph,  and  the  lymph  feeds 
the  cells." 

3.  The  excretion  of  the  cells,  the  waste  products  of  metabolism, 
are  carried  by  the  lymph  back  into  the  blood-stream,  for  elimination 
through  the  several  emunctories. 

4.  Through  the  lymph  channels  metastasis  frequently  occurs, 
especially  of  malignant  tumor  cells. 

5.  The  lymph  glands  or  nodes  afford  (through  their  product,  the 
phagocytes)  a  very  considerable  protection  against  various  forms  of 
infection. 

—121— 


122  Lymphatics 

6.  By  the  use  of  consistently  osteopathic  procedures,  manipu- 
lative  and  otherwise,  the  lymph  currents  may  be  made  to  serve  as  an 
exceedingly  great  factor  in  the  abortion  of  and  the  recovery  from  a  wide 
range  of  diseases. 

The  practical  value  to  the  physician  of  a  study  of  the  lymphatic 
system  lies  in  the  last  statement  given  above.  It  is  true  that  in  the 
mechanism  of  the  recovery  from  disease  the  lymphatics  automatically  or 
functionally  play  an  important  part,  and  the  osteopath  usually  increases 
their  functional  activity  even  though  he  does  not  realize  how  he  accom- 
plishes it.  If,  however,  he  can  assist  nature's  reparative  efforts  by  con- 
trolling and  utilizing  the  forces  which  are  contained  in  that  all-pervasive 
fluid,  the  lymph,  he  is  so  much  the  better  able  to  cope  with  disease. 

It  will  be  necessary  to  dwell  briefly  on  the  anatomy  of  the  lymph 
vessels  and  glands.  To  obtain  a  fair  conception  of  the  relation  of  the 
lymphatic  system  with  the  blood  circulation,  the  following  from  Gage  will 
be  of  assistance: 

"A  tolerably  correct  pictorial  idea  of  the  entire  vascular  system 
may  be  formed  by  considering  the  blood-vascular  part  as  made  up  of  a 
great  tree,  the  heart  forming  a  short  trunk,  and  the  arteries,  veins  and 
capillaries  the  branches;  but  there  is  present  the  untree-like  character 
of  the  direct  union  of  the  terminal  twigs  of  the  arteries  and  veins,  that 
is,  the  venous  and  arterial  capillaries  are  continuous.  The  lymphatic 
system  may  then  be  represented  by  two  vines  of  unequal  size,  but  which 
together  follow  all  the  blood  vessels  to  their  ultimate  ramifications,  and 
in  many  places  even  send  minute  twigs  beyond  them.  The  analogy 
with  a  vine  is  further  borne  out  by  the  lymphatic  vessels,  as  they  re- 
main of  a  more  uniform  diameter  than  the  blood  vessels;  and  finally,  the 
terminal  twigs,  like  those  of  a  real  vine,  end  freely  or  blindly,  often  in 
slight  expansions  like  leaves,  thus  forming  a  marked  contrast  with  the 
terminal  twigs  of  arteries  and  veins,  which  cannot  properly  be  said  to 
terminate  at  all.  In  a  word,  the  blood-vascular  system  forms  a  com- 
plete circle  or  circuit  in  itself,  while  the  lymph-vascular  system  joins 
the  blood-vascular  system  at  its  central  or  trunk  end,  but  ends  blindly 
at  the  periphery. " 

One  might  with  propriety  carry  out  Gage's  picture  by  imagining 
the  tree  and  vine  enclosed  in  a  huge  bag.  In  that  case  the  terminal  twigs 
and  leaves  and  tendrils  of  the  vine  would  not  only  fiU  all  of  the  space 
between  the  tree  branches,  but  would  puvsh  out  into  the  substance  of 
the  bag  as  well.  F'or  lymph  ducts  penetrate  nearly  all  the  structures, 
including  the  corium  (beyond  which  the  lymph  passes  into  the  rete  Mal- 
pighii),  and  many  perivascular  spaces  and  other  interstices  are  filled 
with  loose  connective  tissue  which  is  permeated  with  lymph. 


Origin  and  Function  123 

The  Volume  of  Lymph 

The  total  volume  of  the  lymph  is  consequently  enormous.  Experi- 
menters, through  different  methods  of  determination  and  different  con- 
ditions  of  the  body,  have  variously  estimated  the  amount  of  lymph  to 
be  from  1-6  up  to  1-3  of  the  total  body  volume.  The  volume  of  the 
blood  ranges  from  1-15  to  1-11*  of  that  of  the  body,  tf  from  these  sev- 
eral estimates  we  use  as  a  mean  ratio  1-4  to  represent  the  volume  of  the 
lymph,  and  1-12  that  of  the  blood,  we  find  that  there  is  about  three  times 
as  much  lymph  as  blood.  Even  if  it  performed  no  important  function, 
the  mere  mass  or  bulk  of  this  fluid  would  compel  us  to  view  it  as  having 
no  small  influence  in  the  economy  of  the  body.  And  since  its  mission 
is  so  vital  to  all  the  structures,  w^  cannot  regard  it  lightly. 

This  immense  body  of  fluid  constitutes  a  medium  of  exchange  so 
universal  that  man  has  been  described,  not  inaptly,  as  an  aquatic  animal. 
Every  cell  is  bathed  in  lymph.  Every  cell  depends  upon  the  lymph  for 
nourishment.  Every  cell  is  afforded  drainage  by  means  of  the  lymph. 
As  Byron  Robinson  says,  the  lymph  performs  an  import  and  export  duty;" 
carries  on  a  commerce  with  every  other  tissue. 

Development  of  Lymphatics 

A  series  of  studies  made  on  pig  embryos  by  Dr.  Florence  R.  Sabin 
of  Johns  Hopkins  University  demonstrated  the  fact  that  the  lymphatic 
vessels  are  developed  from  the  veins.  Her  highly  interesting  reports 
of  these  studies  are  embodied  in  three  papers  contributed  to  the  Amer- 
ican Journal  of  Anatomy.  Injection  of  large  numbers  of  embryos  in 
various  stages  of  developmentf  showed  that  the  lymphatics  begin  to 
bud  out  from  the  veins  at  four  points — two  in  the  veins  of  the  neck,  and 
later  two  in  the  inguinal  region.  As  authority  for  the  statement  that 
the  lymphatics  do  not  develop  as  a  separate  system,  but  are  an  out- 
growth or  appendage  of  the  venous  system,  I  quote  Dr.  Sabin: 

"The  proof  that  the  lymphatic  ducts  bud  off  from  the  veins  is  as 
follows:  It  has  been  established  that  the  ducts  invade  the  skin  from 
four  points,  two  anterior  and  two  posterior,  and  that  the  growth  is  from 
center  to  periphery.  Starting  from  the  time  when  the  ducts  have  com- 
plet^lj^  covered  the  skin,  every  stage  has  been  followed  backward  until 

■•■The  results  of  74  expeiimcnts  by  the  carbon  monoxid  method  showed  only  five  per  cent,  or  I  :;0 
of  the  body  weight  to  be  the  actual  weight  of  the  blood. 

tDr.  Sabin  says:  "The  development  of  the  lymphatic  system  was  found  in  this  way.  We  have 
an  abundant  supply  of  pig  embryos  at  the  Anatomical  Laboratory.  Everj-  day  large  numbers  of  em- 
bryos of  all  sizes  from  under  10  mm.  upwards  are  brought  to  the  laboratorj-.  Moreover,  we  are  so  near 
the  abbatoir  that  the  embryos  are  often  brought  with  the  heart  still  beating.  It  is  essential  in  injecting 
lymphatics  to  have  fresh  embrjos,  for  aftei  an  embrjo  is  once  thoroughly  ccld  it  is  impossible  to  get  good 
injections.     The  best  results  are  alwavs  obtained  while  the  heart  is  still  beating." 


Plate  XXX. — The  principal  nerve  tracts  are  shown  including  some  of  the  cranial 
nerves.  We  have  drawn  in  a  few  IjTnph  nodes  to  show  the  relation  of  the  nodes 
to  the  nerve  branches.  The  thoracic  duct  and  receptaculum  chyli  have  been 
drawn  upward  a  few  spinal  segments  to  more  clearly  illustrate  the  solar  plexus. 


Origin  and  Function  125 

the  ducts  are  extremely  small  and  extend  only  a  short  distance  from  the 
vein.  In  this  stage  the  opening  into  the  vein  is  just  as  perfect  as  in  the 
later  stages.  Moreover,  previous  to  the  stage  in  which  this  bud  con- 
nected  with  the  vein  is  found,  there  is  no  trace  of  a  lymphatic  duct  or 
sac,  as  there  would  be  if  the  sac  formed  first  and  subsequently  joined  the 
vein. " 

Anatomy  of  the  Lymphatic  System 

For  anatomical  distinction  three  sets  of  lymphatic  vessels  and  glands 
are  noted — the  ectal  or  superficial,  the  ental  or  deep,  and  the  visceral  or 
those  of  the  various  organs.  In  general,  the  superficial  or  subcutaneous 
vessels  follow  the  veins,  while  the  deep  or  subaponeurotic  set  follows  the 
arteries.  In  all  of  them  the  course  of  the  lymph  is  the  same  as  the  ven- 
ous blood-flow,  from  periphery  to  center — though  in  emergencies  this 
may  be  reversed  (through  anastomotic  collateral  vessels)  so  as  to  afford 
cell  nourishment  and  drainage. 

The  lymphatic  vessels  are  richer  in  anastomoses  than  are  the  veins. 
Not  only  do  the  vessels  of  the  different  sets  anastomose  freely  with  others 
of  the  same  set,  but  the  superficial  and  deep  vessels  also  form  frequent 
anastomoses.  The  vessels  are  furnished  with  valves  at  short  intervals. 
The  valves  are  in  pairs,  and  are  crescent-shaped  or  semilunar.  As  the 
lymph  current  has  feebler  propulsive  power  than  that  of  the  blood,  the 
valves  are  more  closely  placed  than  those  of  the  veins.  From  the  hand 
to  the  axilla,  for  instance,  there  are  from  sixty  to  eighty  pairs  of  va-lves. 

While  abundant  anastomosis  is  provided,  and  the  vessels  frequently 
divide  and  subdivide  only  to  converge  again,  the  contents  of  all  of  the 
vessels  pass  through  one  or  more  nodes  or  glands  before  reaching  the 
terminal  collecting  trunks.  Further  allusion  will  be  made  to  this  in 
speaking  of  the  functions  of  the  glands. 

There  are  from  500  to  600  of  these  lymphatic  nodes  or  glands  in  the 
human  body.  They  are  small  bean-like  nodules  developed  from  a  plexus 
or  network  of  the  vessels,  and  are  usually  surrounded  by  loose  connective 
tissue.  In  childhood  they  are  reddish-gray  in  color,  and  on  section  are 
quite  translucent;  in  advanced  life  they  generally  become  atrophied  and 
much  darker  in  color.  They  occur  singly  in  some  positions  (solitarj^ 
glands),  but  generally  in  groups  or  chains.  They  are  so  placed — in 
loose  connective  tissue  and  in  the  flexures  of  joints — as  to  be  freely  mov- 
able. In  consequence  they  admit  of  considerable  enlargement  before 
occasioning  pressure  symptoms. 

The  glands  usually  receive  two  or  more  afferent  vessels.  Gen- 
erally before  entering  the  gland  each  vessel  breaks  up  into  several  smaller 
ones.     The  efferent  vessels  are  larger  and  fewer  in  number.     From  the 


Plate  XXXI.  The  recoptaculum  chyli  and  mesenteric  nodes.  The  inter- 
costal chain  of  nodes  are  drawn  large  to  show  their  position.  The  lower 
six  on  either  f=ide  usually  connect  with  the  receptaculum.  The  upper 
six  with  the  duct  terminals.     (Not  connected  in  this  plate.) 


Origin  and  Function  127 

ease  with  which  they  may  be  observed,  the  cervical,  axillary  and  inguinal 
glands  are  oftenest  noted.  From  the  osteopathic  standpoint,  the  cervical 
glands  receive  the  most  serious  consideration,  but  those  of  the  axilla 
and  groin  may  by  no  means  be  ignored.  A  knowledge  of  the  relations 
of  the  deep  and  superficial  cervical  glands,  their  afferent  and  efferent 
vessels,  and  the  different  structures  drained  by  the  different  glands,  is 
of  the  utmost  importance  to  the  osteopath. 

Lymphoid  or  adenoid  tissue,  similar  in  structure  and  function  to 
the  nodes,  occurs  in  many  situations.  It  has  not  the  organized  glandu- 
lar form  of  the  nodes,  but  consists  of  a  fine  network  of  anastomosing 
cells.  Where  this  tissue  is  clearly  defined  it  is  spoken  of  as  a  follicle. 
In  other  places  it  is  quite  diffuse.  It  is  abundantly  found  in  the  dif- 
fuse form  in  the  entire  digestive  tract,  while  in  the  follicular  aggregations 
it  occurs  in  the  tonsils  and  in  the  small  intestines.  In  the  latter  location 
the  follicles  are  known  as  Peyers  patches  or  agminated  glands. 

Lymphatics  of  the  Intestines 

The  lymphatics  of  the  small  intestines,  while  structurally  and 
functionally  identical  with  the  rest  of  the  system,  possess  the  additional 
function  of  absorbing  the  chyle  through  the  intestinal  stomata.  There 
are  really  two  distinct  sets  of  intestinal  vessels.  Those  of  the  mucosa 
absorb  and  convey  the  chyle,  and  they  alone  can  be  correctly  spoken  of 
as  the  absorbent,  lacteal  or  chyliferous  vessels.  Those  of  the  muscu- 
laris  convey  lymph  only.  Sappey  holds  that  only  the  vessels  of  the 
intestinal  villi  absorb  chyle,  so  that  they  are  the  only  true  lacteal  vessels. 
No  such  distinction  is  usually  made,  it  being  the  custom  to  speak  of  the 
vessels  which  have  their  origin  in  the  small  intestines  as  lacteals.  Ex- 
cept during  digestion,  the  lacteals  carry  lymph  precisely  as  do  the  other 
lymphatic  vessels.* 

The  Nerve  Supply 

Before  taking  up  the  physiology  and  pathology  of  the  lymphatic 
system,  we  must  inquire  as  to  its  nerve  supply.  Until  recently  it  was 
thought  that  the  flow  of  the  lymph  was  due  solely  to  mechanical  forces. 
These  are  respiratory  movements,  intra-abdominal  pressure,  muscular 
contraction,  the  difference  in  pressure  between  the  lymph  capillaries 

*Dr.  Sabin  thus  summarizes  the  development  of  the  lymphatic  system:  "The  lymphatic  system 
is  a  nioditication  of  the  circulatory  system,  dependent  both  in  its  origin,  and  in  large  measure  in  its  de- 
velopment, on  the  blood  vessels.  It  returns  to  the  vascular  system  the  fluid  exuded  into  the  tissue  spaces 
from  the  blood  vessels.  Speaking  more  generally,  it  is  a  system  of  absorbents.  The  lymph  glands,  which 
develop  by  the  increase  of  connective  tissue,  around  the  plexuses  of  ducts,  come  later;  they  occur  only 
in  birds  and  mammals,  and  do  not  begin  to  develop  in  mammalian  embryos  until  the  ducts  or  capillaries 
they  drain  are  well  formed." 


128  Lymphatics 

and  the  terminal  ducts  (pressure  at  the  opening  of  the  ducts  being  very 
low  or  even  negative),  the  inherent  contractility  of  the  vessel  walls, 
VIS  A  TERGO,  etc.  The  thirteenth  edition  of  Gray's  Anatomy  contains 
the  following  statement : 

"The  lymphatics  are  suppHed  by  nutrient  vessels,  which  are  dis- 
tributed to  their  outer  and  middle  coats;  but  no  nerves  have  at  present 
been  traced  into  them."  In  the  latest  edition  the  last  clause  is  replaced 
by  the  following:  "and  here  also  have  been  traced  many  non-medulated 
nerve-fibres  in  the  form  of  a  fine  plexus  of  fibrils."  Concerning  the 
glands,  the  following  appears  in  Gray:  "Little  is  known  of  the  nerves, 
though  KoUiker  describes  some  fine  nervous  filaments  passing  into  the 
hilum." 

Some  modern  authorities  still  ignore  the  presence  of  nerves  in  the 
lymph  vessels  and  glands.  Kirkes  mentions  evidence  of  sympathetic 
(vasomotor)  nerves  in  the  thoracic  duct,  but  ascribes  the  flow  of  lymph 
to  other  than  nervous  impulses.  Gage,  in  his  splendid  monograph  on 
The  Lymphatic  System,  makes  no  reference  to  the  nerves  of  the  vessels. 
I  have  searched  in  vain  for  allusion  to  the  nerve  supply  of  the  lymphatics 
in  the  works  of  several  writers  on  the  pathology  of  the  glands.  Hall  - 
says:     "The  flow  of  lymph  seems  to  be  without  direct  nervous  control." 

On  the  other  hand,  Landois  says:  "The  nervous  system  has  a  di- 
rect influence  upon  the  movement  of  IjTnph  through  innervation  of  ther 
muscles  of  the  lymphatics.  In  addition  there  are  still  other  special 
effects  of  the  nerves  upon  the  absorptive  activity  of  the  lymphatic  rad- 
icles." Landois  also  mentions  Golz's  experiment,  which  was  as  fol- 
lows. He  injected  a  dilute  salt  solution  into  the  subcutaneous  lymph 
spaces,  and  found  that  it  was  readily  absorbed.  The  absorption  was 
retarded  by  division  of  the  nerves  to  the  extremities,  and  the  destruction 
of  the  central  nervous  system  caused  the  solution  to  remain  unabsorbed. 

Delamere,  in  "The  Lymphatics"  (probably  the  most  complete  work 
on  the  lymphatic  system  that  is  pubUshed  in  English),  states  that  the 
walls  of  the  lymphatic  tnmks  are  rich  in  nerves,  and  supports  the  state- 
ment by  quoting  various  investigators.  For  instance,  Dogiel  and  De 
Timofejewsky  saw  nerve  filaments  surrounding  the  lymphatics  of  the 
cord,  the  prepuce  and  the  gall  bladder.  Smirnow  found  both  motor 
and  sensory  nerve-endings  in  the  lymphatics  of  the  cord.  Quenu  and 
Darier  have  seen  fibers  forming  an  adventitious  plexus  in  the  thoracic 
duct  of  the  dog.  Kytmanoff  also  is  quoted.  He  believes,  from  re- 
searches conducted  according  to  Ehrlich's  method,  that  while  the  nerves 
of  the  lymphatics  are  formed  chiefly  by  the  fibers  of  Remak,  they  con- 
tain some  fibers  with  myelin.     He  describes  adventitious,  supra-muscular 


Origin  and  Function 


129 


Plate  XXXII.  Without  proper  lymph  drainage  the  spinal  cord  and  mem- 
branes would  lack  in  their  functions.  The  lymph  flow  must  be  kept 
normal  as  well  as  the  vascularization  of  the  cord. 


130  Lymphatics 

and  sub-endothelial  plexuses.  There  are  motor  terminations  in  the 
muscular  fibers,  while  the  terminations  of  the  sensory  nerves  are  in  the 
external  and  middle  coats  of  the  vessels. 

Hazzard  in  his  Practice  of  Osteopathy  quotes  Dr.  Still's  views  on 
the  innervation  of  the  lymphatic  system  and  especially  of  the  thoracic 
duct,  with  particular  reference  to  the  causation  of  obesity.  He  says: 
"Dr.  Still  points  out  spinal  lesion  to  the  full  length  of  the  thoracic  duct, 
acting  through  the  various  spinal  sympathetic  connections,  splanchnics, 
etc.  He  mentions  especially  lesion  at  the  4th  dorsal,  which  he  calls  a 
center  for  nutrition,  and  at  the  7th  cervical,  opposite  which  the  duct  ends. 
He  has  called  attention  to  lesion  in  the  upper  dorsal  region,  just  below 
the  cervical,  giving  rise  to  the  growth  of  a  fleshy  cushion,  a  condition  of 
affairs  that  seems  to  influence  the  lymphatic  system  and  cause  a  deposi- 
tion of  fat.  He  also  works  high  in  the  cervical  region,  opposite  the  trans- 
verse processes  of  the  vertebrae,  for  nerves  controlling  the  cahber  of  the 
duct." 

In  his  last  book,  "The  Abdominal  and  Pelvic  Brain,"  Byron  Robin- 1 
son  employed  the  following  language  to  show  the  vasomotor  control 
of  the  lymphatics:  "The  functioning  of  the  tractus  lymphaticus  (sen- 
sation, peristalsis,  absorption  and  secretion)  is  controlled  by  the  nervus 
vasomotorius  (sympathetic).  The  tractus  lymphaticus  is  richly  sup- 
plied by  a  plexiform,  nodular  network,  a  fenestrated  anastomosed  mesh- 
work  of  the  nervus  Vasomotorius  which  controls  its  physiology. " 

In  view  of  the  findings  of  many  investigators,  the  authority  of  Dr. 
Still  (which  is  no  doubt  somewhat  empirical,  being  based  probably  on 
clinical  experience),  and  the  positive  assertion  of  so  great  an  anatomist 
as  Robinson,  we  are  justified  in  accepting  the  vasomotor  control  of  the 
lymph  vessels,  subject,  however,  to  the  mechanical  influences  alluded  to 
above. 

The  Movement  of  the  Lymph 

Let  us  revert  to  the  general  movement  of  lymph,  beginning  with 
its  transudation  through  the  walls  of  the  blood  capillaries.  At  the  but- 
set  we  are  confronted  by  conflicting  views  of  the  origin  of  the  lymph 
plasma.  By  some  it  is  thought  to  be  solely  an  infiltration  of  blood  plasma 
by  osmosis  through  the  capillary  walls.  A  larger  number  believe  it 
contains  in  addition  a  secretion  of  the  capillary  endothelium — a  pro- 
duct of  cellular  activity.  The  fact  that  it  differs  in  chemical  composi- 
tion from  the  blood  plasma  seems  to  prove  the  latter  point  to  be  correct. 
It  is  a  slightly  viscid,  alkaline  fluid,  nearly  colorless  and  odorless,  varying 
somewhat  in  different  locations,  and  carrying  variable  numbers  of  leuco- 


Origin  and  Function  131 

cytes.  The  leucocytes  are  regarded  as  casual  guests  of  the  Ijnnph,  and 
not  an  essential  part  of  it. 

Passing  into  the  intercellular  lymph  spaces  beyond  the  capillaries, 
bathing  all  the  cells  and  supplying  them  with  the  nutrient  properties  it 
contains,  and  receiving  their  excretions,  the  lymph  begins  its  journey 
back  to  the  blood-stream.  Laden  with  katabolic  products,  it  enters  the 
lymph  capillaries,  thence  passes  into  the  larger  vessels,  and  is  carried 
along  to  a  lymphatic  node  or  so-called  gland.  It  is  in  these  nodes  that 
some  of  the  leucocytes  (at  least  those  known  as  lymphocytes)  are  gen- 
erated. The  progress  of  the  lymph  is  somewhat  retarded  in  passing 
through  the  nodes,  and  foreign  substances,  whether  living  germs  or  in- 
ert matter,  are  caught  and  imprisoned.  This  accounts  for  the  tender- 
ness and  hypertrophy  of  the  nodes  in  so  many  pathological  conditions. 

Emerging  from  the  gland,  the  lymph  passes  on — generally  through 
several  glands — until  it  reaches  the  lymphatic  duct  on  the  right  or  the 
thoracic  duct  on  the  left.  Through  one  or  the  other  of  these  terminal 
vessels  it  enters  the  blood -stream  at  the  junction  of  the  subclavian  and 
internal  jugular  veins.  Before  again  traversing  the  arteries,  the  lymph 
is  modified  by  entering  the  pulmonary  circulation,  where  it  is  charged 
with  oxygen. 

While  we  must  not  overlook  the  lacteals,  which  during  digestion 
pour  the  chyle  into  the  thoracic  duct,  with  that  exception  we  see  in  the 
lymphatics  a  system  of  closed  ducts.  In  this  respect  the  lymphatic 
system  as  a  whole  resembles  the  spleen  and  other  ductless  glands. 

This  inadequate,  imperfect  and  necessarily  brief  sketch  of  the  lym- 
phatic system  is  presented  in  order  that  the  salient  facts  be  before  the 
mind's  eye.  Much  is  omitted  that  could  profitably  have  been  intro- 
duced did  the  limitations  of  this  chapter  permit.  The  composition  of 
the  lymph  and  chyle,  a  fuller  discussion  of  the  lacteals,  the  question  of 
selectivity  of  the  absorptive  epithelium,  the  structure  of  the  walls  of 
the  vessels  and  the  nodes,  the  evolution  and  degeneration  of  the  leuco- 
cytes and  other  cellular  casual  guests  of  the  lymph — these  and  many 
other  points  could  be  dwelt  upon,  all  having  a  direct  bearing  on  our  main 
subject.  I  trust  that  the  readers'  interest  will  have  been  sufficiently 
aroused  to  induce  them  to  pursue  the  study  further. 

Functions  of  the  Nodes 

An  important  function  of  the  lymphatic  nodes  has  been  only  touched 
upon.  I  refer  to  the  formation  within  them  of  lymph-cells.  Strictly 
speaking,  the  lymph  nodes  are  not  glands  in  the  ordinary  meaning  of 
the  term,  but  they  may  be  classed  with  the  organs  known  as  ductless 


132  Lymphatics 

glands — those  forming  an  "internal  secretion."  In  the  case  of  the 
lymphatic  glands  the  internal  secretion  is  the  lymphocytes.  That  these 
are  most  important  factors  in  phagocytosis  is  seen  by  the  large  number 
of  pathological  conditions  in  which  the  glands  become  inflamed  and 
swollen.  \\  ho  has  not  seen  inguinal  glands  enlarged  and  tender  from 
an  inflamed  corn,  or  axillary  glands  exquisitely  painful  from  a  boil  on 
the  forearm?  These  simple  forms  of  lymphangitis  are  quickly  abated  with 
the  subsidence  of  the  original  inflammation.  It  is  amply  proven  that 
in  these,  as  well  as  in  graver  conditions,  every  measure  which  aids  the  for- 
mation and  circulation  of  lymph  helps  to  relieve  the  inflammatory  state. 

Lymph  and  the  Endocrlnes 

All  of  the  foregoing  portion  of  this  chapter  was  written  several  3'ears 
ago,  and  the  author  sees  no  occasion  to  change  or  revise  it  thus  far.  He 
desires,  however,  to  direct  attention  to  the  next  two  paragraphs,whi(}h 
were  also  written  at  the  same  time: 

"Another  function  of  the  lymphatic  system  which  gives  it  a  peculiar 
interest  to  the  student  of  somatology  is  that  it  affords  a  highway  for  the 
transportation  of  the  internal  secretions  of  the  other  ductless  glands. 
We  know  comparatively  little  of  the  real  office  of  the  pituitary  body, 
the  pineal  gland,  the  thyroid  body,  the  spleen,  the  suprarenal  capsules. 
Enough  has  been  demonstrated,  however,  by  extirpation,  by  injection 
oi  glandular  extracts,  by  transplantation,  and  by  study  of  diseases  in 
which  the  function  of  a  gland  is  impaired  or  suspended,  to  prove  that 
these  ductless  glands  profoundly  affect  metabolism  through  the  utiliza- 
tion of  their  secretions  by  other  parts  of  the  organism.  How  quickly 
then  will  the  equilibrium  be  disturbed  by  any  interference  with  the  free 
distribution  of  the  lymph  which  bears  these  secretions  in  its  currents. 

"Again,  may  it  not  be  true  that  in  diseases  of  the  ductless  glands  a 
great  help  toward  establishing  a  cure  is  to  be  found  in  agencies  that  tend 
to  increase  lymph  pressure  and  flow?  For  example,  take  Graves'  dis-r 
ease  and  the  serious  symptoms  it  presents  (tachycardia,  digestive  dis- 
orders, extreme  prostration,  exophthalmos,  tremors,  etc.)  and  the  well- 
demonstrated  fact  that  osteopathic  treatment  causes  marked  improve- 
ment. Can  we  show  that  correction  of  the  lesions  which  are  found  in 
these  cases  directly  produces  the  benefit  manifested?  Not  always,  I 
believe.  May  it  not  then  be  reasonably  assumed  that  those  symptoms 
at  least  which  are  referable  to  the  auto-intoxication  caused  by  a  modi- 
fied distribution  of  the  thyroid's  internal  secretion  are  due  in  part  to 
failure  of  the  lymph  to  properly  transport  the  secretion?  In  such  event, 
may  not  the  treatment  administered  to  correct  the  anatomical  faidts 
give  the  lymph  the  needed  impetus?" 


Origin  .\nd  Function 


133 


Plate  XXXIII. — "Intramural"  (within  the  walls).  1,  Dura  Mater;  2,  3, 
and  4,  Periosteal  lining;  o,  Posterior  ganglion;  6,  Anterior  nerve 
roots;  7,  Anterior  horn;  8,  Posterior  horn;  9,  Anterior  median  fis.sure; 
10,  Union  of  anterior  and  posterior  spinal  nerve  roots,  11,  Ligamentum 
denticulatmn;  12,  Spinous  process;  13,  Ligament;  14,  Body  of  ver- 
tebra; In.  Disc  between  vertebrae.  The  cerebrospinal  fluid  contained 
in  this  area  is  a  modified  form  of  Ijnnph.  Normal  nerve  tone  depends 
on  good  lymph  drainage. 


134  Lymphatics 

The  tibove  suggestions,  though  made  empirically,  seem  to  be  justi- 
fied by  recent  research  into  the  functions  and  relations  of  the  ductless 
glands.  Again  quoting  the  axiom  that  the  blood  feeds  the  lymph  and 
the  lymph  feeds  the  cells,  we  must  see  the  supreme  importance  of  free 
lymphatic  activity. 

In  this  connection  permit  a  further  quotation: 

"Now  that  we  know  the  important  relation  existing  between  the 
various  secretory  glands,  and  among  these  the  ovary  and  the  testicle 
are  not  the  least  important,  we  can  understand  that  in  dementia  precox 
menstruation  is  delayed  or  that  there  is  sexual  precocity,  for  menstrua- 
tion is  a  pluriglandular  cyclic  process.  We  can  understand  sexual  ex- 
cesses, vagaries  and  perversions.  It  is  easily  understood  why  the  symp- 
toms are  brought  out  or  accentuated  by  menstruation  or  brought  on  by 
pregnancy,  repeated  pregnancy,  or  by  miscarriage.     Hence  dementia 

PRECOX  IS  A  SERIOUS  AND  EXTREME  TYPE  OF  ENDOCRINE  ABERRATION 
OR   ABNORMALITY   EVIDENCING    ITS   PRESENCE   BY   PSYCHIC   RATHER   THAN 

SOMATIC  ALTERATIONS.  So  as  we  delve  into  one  mental  aberration 
after  another,  the  internal  secretory  glands  seem  to  be  more  and  more 
related  to  conditions  characterized  by  psychic  manifestations. 

"The  physical  and  mental  development  of  the  individual  are  de- 
pendent on  the  action  and  interaction  of  the  ductless  glands.  The  nu- 
trition of  the  body,  of  the  mind  and  of  the  sex  organs,  as  we  are  learning 
more  and  more,  are  dependent  on  the  trophic  stimuli  of  the  ductless  gland 
system.  Long  before  the  trophic  relation  between  the  various  glands 
and  the  ovary  is  evidenced  by  menstruation  and  development  of  the 
secondary  sex  characteristics,  these  glands  are  concerned  with  the  body 
growth. 

"The  physical  and  mental  development  of  a  growing  child  is  de- 
pendent upon  the  activity  of  the  hypophysis  gland  and  particularly  the 
thyroid  gland.  Bony  growth  is  of  course  related  to  calcium  metabolism 
and  here  the  thymus  and  the  parathyroids  and  adrenals  are  of  importance. 
The  thymus  and  the  parathyroid  glands  are  particularly  concerned  with 
calcium  metabolism  and,  to  this  degree  and  probably  in  ways  which  we 
do  not  yet  understand,  they  are  intimately  associated  therefore  with 
bony  growth  and  the  development  of  the  skeleton.  We  do  know  that 
hypothymism  causes  short  bones,  thin  bones,  fragile  bones.  We  know 
the  lack  of  physical  and  mental  development  in  cretinism.  We  know 
that  dwarfs  ma}-  also  be  due  to  an  underactivity  of  the  hypophysis  gland."* 

I  would  direct  attention  to  that  common  affection  of  the  cervical 
nodes,  tubercular  adenitis.     So  frequently  does  it  occur  in  childhood 

"Handler:     The  Endocrines.     W.  B.  Saunders  Co..  1920. 


Origin  and  Function  135 

that  one  writer  says  96  per  cent  of  all  children  become  infected  at  one 
time  or  another  with  tuberculosis  of  the  cervical  lymphatics.  The  fact 
that  so  often  a  tubercular  gland  or  group  of  glands  will  remain  quiescent 
for  a  long  period  may  lead  to  the  belief  that  there  exists  a  simple  ade- 
nitis, and  local  treatment  may  light  up  the  tubercular  process,  with 
very  bad  results.  If  there  is  any  likelihood  whatever  of  tubercular 
infection  all  work  in  the  cervical  region  should  be  done  in  the  most  guarded 
manner,  to  avoid  causing  inflammation  which  may  terminate  in  suppu- 
ration. Glands  which  have  softened  can  be  dealt  with  only  surgically. 
The  general  treatment  of  the  patient  in  all  such  tuberculous  cases  is  the 
same  as  in  pulmonary  and  other  forms  of  tuberculosis — outdoor  life, 
an  abundance  of  nutritious,  easily  digested  food,  together  with  ap- 
propriate osteopathic  treatment. 

Transubstantlation  In  the  Lymph-Stream 

In  searching  for  the  elusive,  mysterious  seat  of  that  "transubstan- 
tlation" whereby  the  assimilated  portion  of  the  ingested  bread  becomes 
the  actual  body;  in  seeking  to  uncover  that  stage  of  the  anabolic  process 
at  which  protein  is  transformed  into  protoplasm,  it  is  through  the  lymph- 
stream  that  we  shall,  if  ever,  discover  the  ultimate  metamorphosis. 

The  Lymph  and  Nutrition 

To  the  inquiring  mind  countless  channels  of  thought  are  opened  by 
questioning  the  influence  of  lymph  formation  and  flow  in  relation  to 
many  diseases.  How  can  we  direct  nutrition  to  impoverished  cells? 
How  can  we  through  the  lymphatics  reach  and  stimulate  the  emunctories 
and  accelerate  excretions?  If  we  learn  to  accomplish  these  and  other 
results,  in  some  measure,  then  is  this  study  not  wholly  in  vain,  and  it. 
behooves  us  to  hearken  to  Dr.  Still  as  he  bids  us  to  "go  deeper."  In  the 
present  chapter  I  can  do  little  more  than  indicate  sonie  possibilities. 
The  questions  may  be  taken  up  in  a  later  article,  but  in  the  meantime 
each  must  elaborate  the  subject  for  himself. 

The  Commissary  Department 

The  lymphatic  system  is  as  necessary  to  the  body  as  the  quarter- 
master department  is  to  an  army.  The  army  may  have  the  finest  uni- 
forms, the  best  ammunition,  and  all  the  accompanying  impedimenta, 
but  if  provisions  are  not  forthcoming  there  is  speedy  disintegration. 
The  whole  mechanism  is  upset.  So  with  the  body.  Without  the  con- 
tinual supply  of  lymph  to  all  the  parts  we  would  have  wasting,  disease, 
and  death.  Every  living  cell  must  have  its  continual  supply  of  nu- 
trition, or  it  will  cease  functioning. 


136  Lymphatics 

When  the  amiy  is  going  through  a  battle  the  supplies  must  still  keep 
coming,  in  greater  abundance  and  with  greater  efficiency  than  before. 
If  the  depletion  in  the  ranks  is  too  great,  sometimes  the  deficiency  in 
the  fighting  force  is  filled  by  members  of  the  quartermaster  corps,  who 
fall  into  the  breach  and  are  quickly  developed  into  fighting  men.  They 
may  not  perform  their  new  duties  so  well  as  the  trained  regulars,  but  after 
a  time  it  would  be  almost  impossible  to  distinguish  them  from  the  vet- 
erans. 

The  Lymph  in  Orthopedic  Surgery 

Here  we  can  draw  a  very  fair  comparison  between  an  army  and  the 
body.  The  lymph  plays  an  all-important  part  in  the  metabolic  pro- 
cesses, through  its  double  role  of  nutritional  supply  and  filtering  process 
in  the  nodes,  but  in  regeneration  of  tissue  it  takes  on  a  third  function, 
namely,  cell  forming.  This  function  is  very  necessary  in  repair  cases, 
following  operation,  and  so  must  be  of  great  interest  to  the  orthopedic 
surgeon,  who  looks  for  the  formation  of  new  tissues  and  structures.  Here 
it  is  that  the  lymph  throws  its  cells  into  the  breach  to  fill  up  the  gaps 
in  the  ranks  of  the  regulars. 

Take  the  simple  operation  of  subcutaneous  tenotomy,  so  necessary 
in  many  cases  of  talipes,  particularly  those  of  the  equinus  typ)es.  It  is 
not  unusual  in  the  author's  experience  to  sever  the  tendo  Achillis  without 
the  external  loss  of  two  drops  of  blood,  by  making  an  incision  parallel 
to  the  tendon  and  turning  the  knife  so  as  to  cut  squarely  across  the  ten- 
don. What  follows?  There  is  rapid  exudation  of  lymph  from  both 
cut  ends,  and  new  cells  are  formed  to  fill  the  interspace,  though  it  be  an 
inch  or  more  in  extent.  Within  eight  weeks  new  tendon  and  sheath  fill 
the  gap.  The  external  wound  is  scarcely  visible  and  the  new  portion  of 
the  tendon  is  fully  as  strong  as  the  old. 

In  any  process  of  regeneration  there  must  be  the  regular  line  tissue 
which  leads  in  the  action.  We  look  back  to  the  embryo,  even  back  to 
the  blastula  and  gastrula  stages  in  the  development  of  any  animal,  and 
we  find  that  development  took  place  in  regular  lines  and  layers  of  cells, 
uniform  and  homogeneous.  Later,  some  of  these  cells,  or  groups  of 
cells,  were  cut  off  from  the  rest  of  the  regular  layer,  and  then  began  to 
take  on  new  characteristics.  They  became  specialized,  and  lost  all  ap- 
parent connection  with  their  primitive  brethren.  In  the  main,  how- 
ever, the  greater  part  of  these  first  cells  developed,  and  in  the  mature 
human  we  find  them  divided  into  two  great  classes,  epithelium  and  en- 
dothelium. The  epithelium  refers  to  the  layers  of  cells  which  line  all 
systems  which  open  into  the  exterior,  such  as  the  skin,  digestive  tract, 
respiratory  tract,  and  the  uro-genital  tract.     Endothelium  means  the 


Origin  and  Function  137 

layers  of  cells  which  line  all  closed  systems — blood  vessels,  peritoneum, 
pleura,  etc.  These  are  in  reality  primitive  cells,  and  it  is  these  cells 
which  are  most  easily  replaced. 

In  regeneration,  then,  the  organs  which  are  most  quickly  repaired 
must  necessarily  be  those  which  have  epithelial  or  endothelial  connec- 
tions. A  wound  in  the  skin,  for  example,  if  it  heals  by  first  intention, 
will  very  quickly  be  restored  to  normal.  The  epithelial  cells  in  the  im- 
mediate vicinity  react  with  astonishing  rapidity.  An  extra  supply  of 
lymph  is  rushed  in,  and  lymphocytes  are  ingested  in  great  quantities 
by  the  epithelial  warriors.  They  don't  even  wait  to  take  food  from  the 
cells;  they  take  cells  and  all,  and  in  their  increased  metabolic  activity 
transfer  everything  into  their  own  protoplasm.  Thus  active  karyo- 
kinesis  is  established,  the  epithelial  cells  become  spindle-shaped  as  they 
go  on  developing,  fibroblasts  are  formed,  and  soon  we  find  that  these 
primitive  cells  have  made  themselves  into  the  next  number  in  the  series, 
connective  tissue.  Some  authors  say  that  connective  tissue  is  the  most 
primitive,  in  that  it  never  develops  very  highly,  but  from  an  embryo- 
logical  standpoint,  surely,  epithelial  tissue  has  every  claim.  The  ex- 
ception, of  course,  is  nervous  tissue,  which  comes  directly  from  the  ec- 
todermal layer,  but  it  goes  through  so  much  differentiation,  this  master 
tissue,  that  it  is  hardly  just  to  classify  it  with  epithelium. 

This  newly-formed  tissue,  unless  it  is  very  superficial,  will  not  be- 
come exactly  like  the  old  structure,  but  a  cicatrix  will  be  left,  composed 
of  white  fibrous  connective  tissue,  formed  from  the  epithelial  fibroblasts. 
Even  before  this  process  is  finished,  to  illustrate  how  important  is  nu- 
trition, the  lymph  capillaries  in  the  region  surrounding  the  cicatrix  bring 
increased  pressure  to  bear  by  dilating  with  their  fluid,  and  actually  push 
their  endothelial  linings  through  the  hard,  heterogeneous  mass  in  order 
to  rush  in  supplies  to  the  newly-formed  member.  The  blood  vessels, 
of  course,  are  doing  likewise,  because  there  is  always  harmony  of  action 
between  the  blood  and  lymphatic  circulation. 

When  big  gaps  are  made  in  structures,  as  in  the  case  of  an  opera- 
tion when  part  of  a  structure  is  removed,  the  parenchymatous  cells  are 
not  regenerated.  Specialization  has  gone  on  too  far  for  new  cells  to  be 
regenerated  from  primitive  tissue.  The  veterans  have  been  destroyed. 
They  cannot  be  replaced.  The  space  is  filled  with  a  debris  of  blood 
cells,  epithelial  and  endothelial  cells,  and  a  great  deal  of  lymph.  At 
first  there  is  only  a  mass  of  material,  an  indistinguishable  conglomeration. 
Gradually,  however,  the  forces  of  nature  begin  to  pick  and  choose,  the 
chaff  is  separated  from  the  wheat,  and  organization  begins  to  come  out 
of  chaos.     The  live  cells  ingest  food  and  undergo  karyokinesis.     The 


138 


Lymphatics 


Pirate  XXXIV.  Several  sections  of  the  cord  are  shown  to  bring  out  the 
idea  of  the  circulation  in  the  cord  segments.  The  lymph  vessels  and 
spaces  fellow  the  course  of  the  blood  vessels  and  capillaries.  Perfect 
IjTnph  drainage  helps  to  msure  normal  nerve  stability. 


Origin  and  Function  139 

lymph  stream  carries  off  the  products  of  metabolism  and  other  waste 
and  poisons  collected  in  this  region,  connective  tissue  is  formed,  and 
soon  the  regeneration  has  taken  place,  the  structure  is  once  more  com- 
plete. In  tissues  where  great  specialization  has  not  taken  place,  as  in 
tendon,  cartilage  and  bone,  practically  complete  restoration  of  the  origi- 
nal  tissue  is  the  result,  providing  that  the  germinal  epithelial  linings 
(i.  e.  periosteum  and  perichondrium)  have  been  preserved.  In  organs 
where  great  specialization  has  taken  place,  as  in  the  kidney,  restoration 
of  the  parenchyma  is  not  effected. 

To  Stimulate  Lymph  Flow 

Regarding  the  flow  Kirkessays:  "The  flow  of  lymph  may  be  in- 
creased  by  increasing  the  capillary  pressure.  This  may  be  done  by  in- 
jecting  a  large  amount  of  fluid  into  the  circulation,  or  by  the  injection  of 
such  substances  as  sugar  and  salt  into  the  blood."  Various  observers 
hold  that  the  receptaculum  chyli  undergoes  rhythmical  contractions,  in 
which  case  we  may  conclude  that  the  pressure  and  flow  of  lymph  are 
greatly  increased  after  the  ingestion  of  food.  Some  drugs  (as  curare) 
increase  the  flow  of  lymph,  and  it  can  be  done  locally  by  ligation  of  the 
veins.  Bier's  constriction  method  of  inducing  local  passive  hyperemia 
deserves  mention.  However,  with  none  of  these  means  have  we  at 
present  any  concern. 

Among  the  noteworthy  methods  are:  (1)  Deep  breathing.  With 
each  inspiration  the  flow  of  blood  through  the  innominate  veins  causes 
a  suction  at  the  openings  of  the  thoracic  and  right  lymphatic  ducts. 
This  may  be  augmented  by  intra-abdominal  pressure  if  the  abdomen  be 
forcibly  drawn  in.  (2)  Manipulation  of  the  extremities  by  flexion  of 
the  joints  and  compression  of  muscles.  This  may  be  either  active  or 
passive.  (3)  Raising  intra-abdominal  blood-pressure  by  direct  work 
over  the  abdomen  and  by  compressing  the  ribs.  (4)  Restoring  normal 
tone  to  the  diaphragm  if  it  is  prolapsed  or  relaxed.  Dr.  Still  suggests 
that  such  prolapse  may  cause  embarrassment  to  the  thoracic  duct. 
Hazzard  elaborates  this  suggestion  in  a  chapt-er  in  his  Practice  entitled 
"An  Osteopathic  Study  of  the  Diaphragm,"  which  is  well  worth  pon- 
dering.  (5)  Drinking  hot  water,  or  preferably  hot  salt  solution,  or  in- 
jecting the  same  per  rectum  and  retaining  it. 

To  Increase  the  Volume  of  Lymph 

The  VOLUME  of  lymph  may  be  increased  in  various  ways,  among 
which  may  be  mentioned  (1)  Active  and  passive  muscular  movements. 
Landois  says:  "Muscular  activity  causes  increased  lymph  production, 
as  well  as  a  more  rapid  escape  of  the  lymph.     The  tendons  and  fasciae 


140  Lymphatics 

of  the  skeletal  muscles,  which  possess  numerous  small  stomata,  absorb 
lymph  from  the  muscular  tissue, "  (2)  Increase  of  blood-pressure  by  any 
of  the  manipulative  means  noted  above.  In  this  connection  readers  are 
commended  to  carefully  study  an  address  given  by  Dr.  Hazzard  at  St. 
Louis  in  1904,  on  "Osteopathic  Manipulation  of  the  Blood-Mass." 
(3)  Quantities  of  hot  water  or  salt  solution  per  os  or  per  rectum.  The 
reason  for  advising  the  use  of  hot  water  rather  than  cold  lies  in  the  fact 
that  heat  dilates  the  blood  vessels,  and  absorption  takes  place  more 
rapidly,  while  cold  water  causes  contraction  of  the  vessels. 

It  will  be  remembered  that  Byron  Robinson  held  that  the  lymphatic 
vessels,  through  their  vasomotor  innervation,  possess  the  four  functions 
of  peristalsis,  absorption,  secretion  and  sensation  (easily  remembered  by 
the  word  pass,  formed  by  the  initial  letters),  and  he  ascribed  the  cause  of 
most  diseases  in  which  the  lymph  and  its  flow  are  concerned  (and  does 
not  this  embrace  much  of  pathology?)  to  either  excessive,  deficient  or 
unbalanced  activity  in  these  functions. 

He  strongly  urged  the  importance  in  constipation  and  other  chronic 
conditions  which  the  osteopath  is  frequently  called  to  treat,  of  giving 
regularly  large  quantities  of  water — better  hot — and  salt.  Seemingly 
afraid  that  his  patients  would  scorn  or  neglect  to  take  plain  salt,  he  gave 
them  NaCl  tablets,  flavored  to  disguise  the  taste,  directing  that  they  be 
placed  on  the  tongue  and  swallowed  with  the  water.  Salt  is  especially 
beneficial  in  that  it  stimulates  the  epithelium  of  the  salivary,  pancreatic 
and  hepatic  glands,  the  entire  digestive  tract,  the  urinary  organs,  etc. 
(The  one  condition  in  which  it  is  contra-indicated  is  parenchymatous 
nephritis,  as  it  is  irritating  to  the  inflamed  kidney  cells.)  Both  blood 
plasma  and  lymph  plasma  contain  more  than  one-half  of  one  per  cent, 
of  salt.  All  of  the  glandular  secretions  contain  salt.  Salt  is  an  im- 
portant digestant,  especially  of  vegetables.  It  is  certainly  a  rational  pro- 
cedure to  promote  cellular  activity  by  making  use  of  this  universal 
stimulant  in  the  manner  indicated  above. 

Why  should  we  seek  to  increase  the  volume  and  flow  of  lymph? 
Because  only  by  having  an  ample  fluid  medium  can  the  maximum  energy 
of  the  cells  be  attained.  It  has  been  proved  by  Metchnikoff,  Bizzozero 
and  others  of  Vi(  chow's  school  that  the  normal  individual  cell  is  endowed 
with  and  exercises  a  power  of  self-defense  and  self-preservation  against 
invasion.  Only  with  a  sufficient  volume  of  lymph  is  normaUty  of  the 
cells  assured — through  irrigation  of  the  lymph  spaces,  maintenance  of 
the  nutrition  of  the  cells,  and  free  drainage  of  the  excretions.  And  only 
through  the  continuance  of  maximum  cellular  activity  can  perfect  health 
be  maintained. 


R.  M.  ASHLEY,  D.  O. 
Detroit,  Mich. 


CHAPTER  EIGHT 

BLOOD  CHEMISTRY 

R.  M.  Ashley,  D.  O.,    Detroit,  Mich.,  1504  Broadway. 
"The  Law  of  the  Artery  is  Supreme  *  *  *  *."— Dr.  A.  T.  Still. 

Upon  the  principle  that  the  blood  is  our  curative  agent,  will  this 
blood  not  give  us  the  best  indication  of  destruction  going  on  within  the 
body?  All  the  tissues  of  the  body  are  bathed  with  blood  and  lymph, 
and  it  seems  only  natural  to  look  to  the  blood  for  pathology  within  these 
tissues. 

If  the  blood  contains  an  abnormal  amount  of  one  or  more  of  its 
component  parts,  certainly  some  part  of  our  anatomy  is  not  functioning 
properly,  and  since  we  know  where  these  various  substances  are  formed, 
will  not  the  blood  analysis  be  a  great  aid  to  us  in  making  our  diagnosis? 
A  thorough  blood  examination  seems  to  me  to  uphold  the  basic  princi- 
pies  of  Osteopathy. 

For  years  Blood  Chemistry  has  been  looked  upon  as  belonging  ex- 
clusively to  experimental  physiological  chemistry,  and  not  in  the  prac- 
tical phase  as  is  urine  and  gastric  analysis.  Not  until  Folin  came  with 
his  Blood  Analyses  as  practical  aids  in  diagnosis,  did  the  professions  con- 
sider them.  Since  his  introduction  of  the  work,  Benedict,  Lewis,  Denis, 
M.  Myers,  and  Fine,  deserve  much  credit  in  introducing  reliable  methods 
for  clinical  laboratory  technique. 

With  the  more  elaborate  technique  required  for  Blood  Chemistry 
the  question  naturally  arises,  of  what  value  is  it  over  the  ordinary  urin- 
alysis to  the  diagnostician?  Here  I  must  hasten  to  add  that  it  far  sur- 
passes the  urinalysis;  rather,  I  should  say,  that  they  should  go  hand  in 
hand.  The  Blood  Chemical  examination  gives  us  an  idea  of  the  retained 
products  of  metabolism  rather  than  the  pathologically  changed  ingred- 
ients of  a  fluid,  such  as  the  search  for  albumin  and  sugar  of  the  urine 
implies.  The  blood  tells  just  what  the  kidneys  are  doing  and  what  they 
are  not  doing,  and  gives  the  exact  status  of  the  nitrogenous  and  carbo- 
hydrate equilibrium. 

The  urine  tells  a  great  deal  about  the  pathology  of  the  kidney,  but 
we  find  in  conditions  such  as  glycosuria,  that  a  blood  analysis  is  far  bet- 
ter. We  may  have  a  great  retention  of  sugar  in  the  blood  before  the 
kidney  permits  it  to  penneate  through.  In  such  cases  only  a  blood 
analysis  would  detect  the  hyperglycemia.  On  the  other  hand,  a  pro- 
nounced glycosuria  may  arise  with  a  relatively  low  grade  hyperglycemia. 
In  renal  diabetes  we  have  no  hyperglycemia,  simply  glycosuria.     With- 

—143— 


144  Lymphatics 

out  chemical  analysis  of  blood,  how  shall  we  dififerentiate  between  renal 
diabetes  and  diabetes  mellitus? 

The  threshold  point,  i.  e.,  the  time  when  the  sugar  increase  in  the 
blood  results  in  a  pouring  out  of  sugar  in  the  urine,  is  a  matter  of  debate. 
Many  investigators  have  arrived  at  as  many  different  threshold  points, 
and  it  is  for  this  reason  that  the  blood  sugar  determinations  are  so  im- 
portant. 

I  have  found  an  example  of  this  in  a  patient  showing  220mg  of  glu- 
cose per  lOOcc  of  blood,  the  normal  blood  sugar  being  from  85mg  to 
lOOcc  of  blood.  Up  to  that  time  the  patient  had  shown  no  sugar  in 
the  urine.  Very  often  a  diabetic  will  starve  himself  for  a  few  days, 
and  become  sugar  free  so  far  as  the  urine  is  concerned,  but  upon  exam- 
ining the  blood,  it  will  be  found  that  the  sugar  though  reduced  is  far 
from  normal.  The  kidneys  may  be  impermeable  to  sugar  up  to  a  very 
high  point.  In  such  a  case  the  blood  sugar  would  be  quite  high,  be- 
fore it  would  appear  in  the  urine.  Folin  (Journal  Biol.  Chem.  1915, 
Vol.  XXII,  P.  327)  states  that  he  could  demonstrate  the  presence  of 
sugar  in  the  human  urine  in  nearly  every  case  examined.  However, 
this  is  by  delicate  technique,  but  it  shows  that  there  is  more  often  sugar 
in  urine  than  ordinary  negative  findings  record. 

It  seems  that  authorities  quite  disagree  as  to  what -is  normal  and 
what  pathological  urine  as  far  as  sugar  is  concerned.  On  the  other 
hand  there  is  little  doubt  as  to  what  constitutes  the  normal  blood  sugar. 
Aside  from  the  liver,  which  Von  Noorden  aptly  calls  ''a  glycogen  reser- 
voir," and  the  muscles  which  he  calls  the  "glycogen  depot"  we  find 
another  source  of  sugar  in  the  proteins.  The  proteins  are  transformed 
into  amino-acids,  such  as  glycocoll  alanine,  aspartic,  and  glutamic  acids, 
and  these  in  turn  go  over  into  dextrose.  The  most  recent  work  bearing 
upon  the  derivation  of  glucose  from  protein  is  that  of  N.  W.  Janey  (Janej', 
N.  W.,  Arch.  Int.  Med.  Nov.  15,  1916,  Vol  XVIII,  No.  5,  Page  584.) 
Contrary  to  existing  opinions,  it  has  been  found  that  the  animal  and 
vegetable  origin  of  proteins  bears  no  relationship  in  their  ability  to 
produce  glucose  within  the  animal  organism,  this  function  being  depend- 
ent almost  entirely  upon  the  sugar-yielding  amino-acids  constituting  the 
various  proteins. 

We  must  distinguish  between  renal  diabetes  and  diabetes  mellitus, 
although  we  have  but  little  pathology  up  to  the  present  time  upon 
which  to  base  our  diagnosis.  Foster  and  Joslin,  who  have  recently  writ- 
ten books  on  diabetes  mellitus,  state  that  the  diagnosis  must  rest  upon 
the  chemical  blood  analysis.  Since  we  have  no  increase  in  the  blood- 
sugar,  in  renal  diabetes,  and  since  we  do  get  a  decided  rise  in  blood-sugar 
in  diabetes  mellitus,  we  will  have  to  base  our  diagnosis  on  these  points. 


Blood  Chemistry  145 

An  instance  of  renal  diabetes  is  the  glycosuria  of  pregnancy.  We 
find  no  increase  in  the  blood  sugar,  and  following  the  puerperium  the 
sugar  in  the  urine  disappears.  Yet  should  these  women  become  preg- 
nant again  they  would  again  show  glycosuria.  However,  in  passing  we 
might  say  that  cases  of  renal  diabetes  are  extremely  rare,  and  in  glyco- 
suria a  thorough  and  exhaustive  study  of  the  blood  should  be  made 
before  coming  to  any  decision. 

The  data  necessary  for  the  diagnosis  of  renal  diabetes  is  quite  defi- 
nite: 

1.  A  glycosuria  running  at  a  general  level  and  not  influenced  ma- 
terially by  the  carbohydrate  intake. 

2.  A  normal  percentage  of  blood  sugar  in  contrast  to  the  increase 
of  sugar  urine. 

A  routine  examination  of  the  blood,  chemically,  will  some  day  be 
required  in  clinical  examinations.  The  methods  of  the  day  are  both 
accurate  and  easy  to  perform  to  one  qualified  to  do  chemical  work. 

In  the  so-called  ahmentary  glycosuria  (Jour.  Am.  Med.  Assn.  Sept. 
2,  1916,  Pg.  748)  we  have  a  condition  within  the  patient  in  which  his 
capacity  for  utilizing  glucose  is  lowered.  In  other  words,  the  sugar 
shows  in  the  urine  by  an  over-indulgence  of  carbohydrate  food.  This 
condition  we  do  not  find  in  a  normally  healthy  individual,  for  the  healthy 
liver  can  store  up  the  excess  of  sugar  as  fast  as  it  is  produced  from  the 
digestion  of  starches.  The  rate  of  entry  of  sugar  into  the  blood  taken 
per  mouth,  depends  upon  a  wide  range  of  physical,  physiologic,  and 
pathologic  conditions,  and  it  will  not  be  possible  to  force  sugar  into 
the  blood  faster  than  it  can  be  absorbed.  When  a  certain  concentra- 
tion is  reached  in  the  blood  no  quantity  of  sugar  given  per  mouth,  sub- 
cutaneously  or  intraperitoneally,  can  raise  it  higher.  Joslin  states  that 
one  per  cent,  of  all  individuals  in  the  United  States  have  diabetes.  This 
is  apparently  a  rapid  increase  over  several  years,  according  to  statis- 
tics. However,  it  merely  means  that  through  the  routine  examination 
of  urine  today  many  more  cases  are  discovered. 

Using  the  latest  methods  of  Myers  and  Bailey  (Jour.  Bio.  Chem. 
1916,  Vol.  XXIV,  pg.  147)  we  find  that  the  amount  of  sugar  is  practically 
the  same  in  blood,  plasma,  and  cells.  It  was  thought  by  the  earlier 
physiologists  that  blood  sugar  was  in  loose  combination  with  other  sub- 
stances in  the  blood.  This  idea  of  course  is  now  obsolete,  for  it  is  known 
conclusively  that  the  blood  sugar  is  in  a  state  of  solution. 

In  conclusion,  let  us  not  forget,  in  cases  of  diabetes,  that  even  though 
the  sugar  disappears  from  the  urine  under  treatment  we  may  have  a  hy- 
perglycemia.    The  rigid  diet  should  be  kept  up  and  blood  analysis  made 


146  Lymphatics 

at  intervals  until  the  blood-sugar  is  normal.  Also  that  a  routine  blood 
analysis  may  discover  sugar  excess  in  the  blood,  long  before  it  shows  in 
the  urine,  thus  giving  the  physician  an  opportunity  to  arrest  further 
progress  of  the  diabetes. 

Spleen 

The  spleen  and  the  stomach  from  the  earliest  times  have  been  sup- 
posed to  possess  some  close  inter-relationship.  Stukeley,  in  1723,  as- 
signed to  the  spleen  the  function  of  stimulating  gastric  digestion.  His 
first  argument  in  favor  of  this  statement  was  the  relative  position  of 
the  two  organs,  and  the  intimate  inter-communication  by  means  of 
their  common  veins,  arteries  and  nerves.  One  is  forced  to  ask  himself 
why  the  principal  blood  vessels  of  the  stomach  arise  from  the  splenic 
artery  in  its  direct  route  to  the  spleen,  and  why  vessels  return  to  the 
stomach  direct  from  the  spleen,  as  does  the  vasa  brevia.  It  has  been 
justly  called  "the  heart  to  the  stomach,"  as  it  seems  always  to  have  a 
supply  of  blood  ready  to  furnish  the  stomach  when  the  call  comes,  and 
later,  when  the  supply  is  not  needed,  the  spleen  can  recall  it. 

It  has  been  suggested  by  Aristotle,  Graecus,  and  Galen  that  the 
spleen  assists  in  warming  the  stomach  against  the  injection  of  cold  foods, 
liquids,  etc.  They  based  their  claim  upon  the  fact  that  animals  that 
drank  great  quantities  of  water  had  large  spleens,  the  size  of  the  organ 
being  regulated  by  the  warmth  needed  to  the  stomach.  As  early  as 
1868  Baccelli,  at  Rome,  demonstrated  a  definite  gastro-splenic  circula- 
tion. He  found  that  the  veins  of  the  vasa  brevia  form  five  or  six  recti- 
linear canals,  with  inter-communicating  smaller  vessels  from  the  spleen 
to  the  cul-de-sac  of  the  stomach,  which  are  devoid  of  valves  so  that  the 
blood  can  pass  in  either  direction.  The  largest  number  of  gastric  glands  are 
situated  in  the  cul-de-sac  at  the  area  supplied  or  drained  by  these  veins. 

The  splenic  artery  in  the  adult  is  the  largest  of  the  three  branches  of 
the  coeliac  axis,  and  is  remarkable  for  the  extreme  tortuosity  of  its  course. 
After  crossing  in  front  of  the  upper  part  of  the  left  kidney,  and  on  arriving 
near  the  spleen,  it  divides,  some  of  the  branches  enter  the  hilum  of  that 
organ,  some  to  the  pancreas  and  others  to  the  greater  curvature  of  the 
stomach.     (Gray,  661.) 

Thus  we  see  that  our  osteopathic  friend,  the  spleen,  has  some  func- 
tion in  connection  with  gastric  digestion  that  still  remains  hazy  in  the 
minds  of  science.  We  are  told  by  some  that  it  aids  in  the  pepsin  secre- 
tion to  the  stomach ;  others,  that  the  removal  of  the  spleen  has  no  effect 
whatever  upon  gastric  secretion.  Whatever  scientific  men  may  think, 
I  am  inclined  to  believe  that  the  general  osteopathic  idea  is  in  favor 
of  the  phagocytic  action  arising  in  this  organ. 


Blood  Chemistry  147 

At  least,  it  is  a  great  field  for  our  osteopathic  research  laboratories 
to  work  on,  and  I  am  sure  they  can  and  will  give  us  some  information  in 
the  near  future  that  will  be  helpful  to  us  individually,  and  as  a  profession. 

Dr.M.  A.  Lane  told  us  that  within  the  spleen  we  have  the  antibodies 
to  fight  off  disease.  He  showed  us  how  to  stimulate  them  to  action,  but 
did  he  tell  us  why  they  acted  thus?  Nevertheless,  it  is  an  osteopathic 
organ,  left  for  osteopaths  to  discover,  and  make  use  of.  In  Hodgkin's 
disease  we  find  splenic  involvement  with  hyperplasia  of  the  lymphatic 
glands,  and  general  anemia. 

Hodgkin's  Disease 

The  blood  counts  in  Hodgkin's  disease  are  unsatisfactory.  We  do 
get  an  increase  of  eosinophiles,  but  it  is  believed  that  the  extensive  cu- 
taneous lesions  may  influence  these.  Levin  makes  an  interesting  ex- 
planation with  regard  to  the  increase  of  lymphocytes.  He  believes  that 
the  terminal  lymphocytosis  is  due  to  the  crowding  full  of  all  the  lymphoid 
tissues  and  an  overflow  of  lymphocytes  into  the  blood  stream.  How- 
ever, he  admits  that  the  blood  count  is  usually  normal  in  Hodgkin's  dis- 
ease. He  says  nothing  of  the  chemical  analysis.  The  lymphoid  tissue 
is  involved  throughout  the  body  generally,  and  the  advised  treatment  is 
Roentgen  Ray.  In  fact,  scientific  writers  have  been  telling  us  for  some 
time  that  the  X-Ray  offers  most  in  mediastinal  complications.  It  re- 
sults in  a  replacement  by  connective  tissue  and  a  diminution  in  the  size 
of  the  glands. 

My  experience  with  blood  chemistry  in  connection  with  Hodgkin's 
disease  has  been  limited  through  lack  of  such  cases;  however,  an  early 
diagnosis  is  the  greatest  advantage  to  both  the  patient  and  the  doctor, 
and  I  think  through  the  blood  we  will  arrive  at  our  conclusions,  aided  by 
physical  examination,  and  accomplish  as  much  or  more  than  bj'^  any 
other  treatment.  Osteopathy  most  certainly  will  build  up  the  Opsonic 
index  of  the  blood,  and  this  alone  will  be  a  great  recommendation  for  it. 

The  Laboratory  Age  will  be  the  Golden  Age  in  osteopathic  diag- 
nosis. While  we  are  as  yet  far  from  being  an  exact  science,  we  have  elim- 
inated much  of  the  inexactness  and  have  located  some  of  that  which 
remains.  Such  an  age  as  that  through  which  we  are  now  passing  forces 
many  hardships  upon  those  who  must  keep  pace  with  advancements  in 
all  fields  of  science.  With  new  discoveries  we  find  many  opportunities 
for  improving  our  technique. 

With  the  preponderance  of  laboratory  study  and  facts,  however, 
some  will  minimize  the  non-laboratory  side  of  our  diagnosis.  We  can- 
not overestimate  the  significance  of  laboratory  findings,  but  we  must 


148  Lymphatics 

not  underestimate  the  non-laboratory  side.  Our  patient,  too,  is  a  lab- 
oratory in  which  actions  are  followed  by  reactions,  and  if  we  can  stim- 
ulate the  proper  chemical  reaction  within  this  human  laboratory'  we 
have  accomplished  our  purpose.  The  time  is  near  at  hand  when  the 
practice  of  Osteopathy  will  be  based  on  an  understanding  which  comes 
from  a  combination  of  facts  derived  from  both  laboratory  investigation, 
and  accurate  observation  of  the  patient,  interpreted  by  a  doctor  who 
KNOWS  HIS  PATIENT  as  he  knows  the  disease,  and  who  refuses  to  shirk 
one  method  in  favor  of  another. 

Acidosis 

In  acidosis  of  the  blood  we  do  not  mean  an  actual  acid  reaction,  for 
this  is  impossible  in  life.  It  is  only  in  the  very  last  stages  of  life  prac- 
tically "in  extermis"  that  an  acid  condition  occurs.  The  neutrality 
of  the  blood  depends  upon  the  mixture  of  carbonic  acid,  carbonates  and 
phosphates.  Carbon  dioxid  is  thrown  off  by  the  lungs,  and  the  urine 
in  health  is  acid  in  reaction  thus  helping  to  maintain  the  alkalinity  of 
the  blood.  Any  excess  of  acids  in  the  blood  seems  to  stimulate  the 
respiratory  centers  in  such  a  way  that  more  CO2  is  thrown  off.  There 
is  also  a  quick  call  on  the  ammonia,  from  the  liver.  It  is  only  when  the 
ammonia  is  being  used  up  that  acidosis  supervenes.  In  the  course  of 
normal  metabolism  we  know  that  the  ammonia  of  the  body  is  converted 
into  urea  and  eliminated  as  such,  but  the  supervening  acidosis  takes  up 
some  of  this  ammonia  and  keeps  the  blood  alkaline.  Our  analysis  in  such 
a  case  would  show  a  reduction  in  the  urea  of  the  urine  as  well  as  a  re- 
duction of  the  ammonia  of  the  blood. 

Respiration  lowers  the  concentration  of  CO2  within  the  lungs,  thus 
allowing  the  CO2  of  greater  concentration  to  pass  from  the  blood  through 
the  alveoli  to  the  plane  of  lower  concentration,  namely,  the  lungs,  and 
be  removed.  It  is  merely  an  exchange  of  different  concentrations  going 
on  continually,  the  greater  displacing  the  lesser  through  osmotic  pressure. 
The  sodium  bicarbonate  occurring  in  the  plasma  and  the  cells,  as  well  as 
alkaline  phosphates  of  sodium  and  potassium  found  in  the  red  cells,  are 
one  of  our  first  line  defenses  against  acidosis.  Thus  we  have  the  alkaline 
compounds  of  blood;  the  kidneys  excreting  an  acid  urine  from  an  alka- 
line blood;  the  production  of  ammonia  and  the  proteins  combining  with 
the  acids  of  the  blood;  all  lines  of  defense  against  the  supervening  acid- 
osis. 

In  the  prevention  of  acidosis  the  consumption  of  fats  must  be  stop- 
ped, since  the  end  product  of  fat  metabolism,  in  the  absence  of  proper 
carbohydrate  balance,  as  in  diabetes,  is  oxybutyric  acid  and  diacetic 


Blood  Chemistry  149 

acid,  instead  of  following  the  normal  path  and  being  transformed  into 
butyric  acid.  There  is  no  further  oxidation.  These  organic  acid  de- 
rivatives of  the  fat  and  protein  matter  of  the  body  furnish  the  basis  for 
the  so-called  acetone  bodies.  When  these  bodies  appear  in  the  urine 
we  have  an  acetonuria  or  a  ketonuria.  The  acetone  of  the  urine  is  ex- 
creted by  the  kidneys  as  diacetic  acid  which  later  changes  to  acetone  by 
dropping  the  (COOH)  radicle. 

CHs— CO— CH3    -acetone. 

CH3— CO— CH2— COOH      -diacetic  acid. 

We  find  an  acid  condition  of  the  blood  very  often  in  infancy  and 
childhood,  in  severe  diarrhoeas  of  infancy,  and  often  alone,  or  rather, 
uncomplicated.  A  difficulty  of  respiration  usually  brings  such  a  con- 
dition to  one's  mind.  Acidosis  is  such  a  fatal  complication  with  infant 
diarrhoea  that  it  is  imperative  that  an  early  diagnosis  be  made.  Bi- 
carbonate of  soda  should  be  administered  to  infants  with  severe  diar- 
rhoeas, as  precautionary  means,  in  quantities  to  keep  the  urine  alkaline. 
This  is  usually  done  intravenously  or  subcutaneously,  intravenous  being 
the  method  of  choice  since  rapidity  of  action  is  always  desired. 

The  variation  in  acid  base  balance  of  the  blood  may  be  stated  as 
follows:  the  blood  bicarbonate  may  be  high,  low,  or  normal,  and  in 
each  of  these  conditions  the  Ph  (hydrogen  ion  concentration)  may  be 
high,  low,  or  normal.  This  would  give  nine  theoretical  conditions  with, 
of  course,  only  one  being  right,  that  is  when  the  bicarbonate  and  the  Ph 
are  within  normal  limits.  At  least  six  of  these  possibilities  can  be  pro- 
duced experimentally  and  some  of  them  occur  clinically.  I  mention  this 
to  bring  to  your  attention  the  wide  range  of  the  acid  base  balance  within 
the-  bod}^  and  the  possibility  of  so  many  abnormal  conditions.  Con- 
cerning the  Ph  of  the  body  fluids,  other  than  blood  plasma,  our  knowledge 
is  limited,  but  all  indications  are  that  all  these  fluids  closely  approximate 
the  blood  plasma  in  action,  or  rather  reaction.  By  the  body  fluids  within 
the  body  proper  we  mean  such  fluids  as  the  lymph,  cerebrospinal  fluid, 
transudates,  exudates,  but  not  secretions  such  ias  gastric  juice  or  urine. 

The  first  effect  of  a  CO?  retention  on  the  blood  is  to  increase  the 
H2CO3  and  the  (H)  of  the  blood.  Davies  and  Haldane  observed,  in 
1920,  that  in  breathing  air  containing  up  to  5%  CO2,  there  was  a  doubling 
of  the  rate  of  ammonia  and  titratable  acid  excretion.  This  increase  in 
ammonia  and  titratable  acid  tends  to  raise  the  bicarbonate  content  of 
the  whole  body,  and  the  blood  plasma  bicarbonate  would  normally  rise 
with  that  of  the  other  fluids.  The  intercellular  fluids,  other  than  blood 
plasma,  have,  so  far  as  studied,  been  found  under  normal  conditions  to 


150  Lymphatics 

approximate  the  blood  plasma  in  bicarbonate  and  hydrogen  concentra- 
tion. In  the  changes  from  normal  the  other  fluids  follow  more  or  less 
promptly  the  blood  plasma.  Van  Slyke  and  Cullen  (1917)  found  that 
when  acid  was  injected  into  the  circulation  the  fall  of  the  blood  bicar- 
bonate was  only  about  one-sixth  as  great  as  it  would  have  been  had  the 
acid  all  remained  in  the  blood ;  the  other  five-sixths  of  the  acid  must  have 
gone  into  other  body  fluids  and  the  tissues,  or  drawn  alkali  from  them, 
thus  neutralizing  itself.  This  gives  us  a  good  idea  of  the  close  relation- 
ship of  the  body  fluids. 

In  cardiac  dyspnea  it  seems  very  likely  that  the  predominant  cause 
of  the  CO2  retention,  resulting  in  an  acidosis,  lies  in  the  lungs.  There  is 
interference  with  the  escape  of  the  CO2  from  the  pulmonary  circulation. 
Possibilities  arising  from  such  a  condition  are:  There  may  be  portions 
of  the  lungs  in  which  the  circulation  is  more  or  less  intact,  but  which 
contain  no  air,  or  there  may  be  portions  of  the  lung  which  are  air  con- 
taining, but  immobile  and  not  adequately  ventilated  by  the  respira- 
tion. This  latter  is  the  view  of  Siebeck  (Siebeck,  R.  Deutch.  Arch.  klin. 
Med.,  1912,  CVII,  253).  However  the  present  methods  of  measuring 
the  lung  volume  has  failed  to  answer  these  ideas,  for  we  are  capable  of 
measuring  only  those  portions  of  the  lung  which  are  air  containing  for 
respiratory  purposes.  Whether  or  not  there  is  a  true  CO2  retention  in 
all  cases  of  cardiac  dyspnea,  there  is  always  interference  with  the  elimina- 
tion of  CO2  from  the  blood,  and  therefore,  a  compensated  or  potential 
acidosis,  (John  P.  Peters,  Jr.  and  David  P.  Barr,  Jour.  Bio.  Chem.  Vol. 
XIV,  No.  3,  Pg.  537). 

In  summarizing  briefly,  it  is  quite  apparent  that  greater  ventilation 
is  necessary  to  effect  the  normal  carbon  dioxid  elimination  in  cardiac 
dj'spnea.  This  lack  of  ventilation  is  largely  brought  about  by  the  im- 
pairment of  the  pulmonary  mechanism  for  the  exchange  of  gases  between 
the  blood  and  the  outside  air.  In  some  cases  the  diminution  of  the  cir- 
culation rate  may  be  an  additional  factor  in  the  production  of  carbon 
dioxid  acidosis.  We  also  find  in  a  certain  number  of  cases  a  reduction 
of  the  available  alkali  of  the  blood. 

From  well  established  facts  regarding  the  process  of  acid  ex- 
cretion in  man,  it  is  absolutely  incorrect  to  assume  a  depletion  of  the 
fixed  alkali  from  an  unusually  acid  urine.  The  neutrality  mechanism 
in  man  is  remarkably  extensible  and  is.  capable  of  neutralizing  and  con- 
veying into  the  urine  unusually  large  amounts  of  acid  without  disturb- 
ance of  the  acid-base  equilibrium  within  the  body.  The  gross  adjust- 
ment of  an  unusual  acid  production  is  an  increase  in  production  of  am- 
monia.    The  fine  adjustment  by  means  of  which  the  reaction  of  the  blood 


Blood  Chemistry  151 

is  maintained  at  the  normal  Ph  is  managed  by  excretion  of  phosphates 
in  correct  relative  amounts.  Slight  variations  in  acid  production  may 
be  entirely  compensated  by  variation  in  the  relative  amounts  of  the 
phosphates  excreted,  the  ammonia  factor  remaining  stationary.  The 
acidity  of  the  urine  on  normal  diets  may  for  this  reason  vary  widely,  the 
hydrogen  ion  concentration  being  frequently  as  great  as  when  acidosis 
is  present.  It  is  therefore  impossible  to  obtain  from  the  hydrogen  ion 
concentration  of  the  urine  a  dependable  indication  of  the  presence  of 
acidosis  throughout  the  body. 

Acidosis  may  be  recognized  in  various  ways,  by  an  increase  in  the 
ammonia  co-efficient  in  the  urine,  decrease  of  carbon  dioxid  tension  of 
alveolar  air,  the  finding  of  abnormal  acid  in  the  blood  and  urine,  in- 
creased alkali  tolerance,  and  by  diminished  titratable  alkalinity  of  the 
blood  serum,  by  changes  in  the  hemoglobin  dissociation  curve,  and  by 
actual  determination  of  the  hydrogen  ion  concentration  of  the  blood. 
A  change  in  the  hydrogen  ion  concentration  of  the  blood  indicates  a 
failure  of  the  protective  mechanism,  and  the  onset  of  acidosis. 

Let  me  call  attention  again  to  the  ammonia  factor  of  the  body.  The 
body  excretes  nitrogen  in  the  form  of  ammonia  from  the  protein.  One 
gram  of  this  ammonia  will  neutralize  five  times  as  much  betaoxybutyric 
acid  as  one  gram  of  sodium  bi-carbonate.  Rowland  (Bulletin  Johns 
Hopkins  Hospital  1916,  Vol.  XXVH,  Pg.  63)  tells  us  that  if  it  were  not 
for  these  alkalies  the  body  would  produce  an  equivalent  to  several  hun- 
dred cubic  centimeters  of  concentrated  hydrochloric  acid  in  the  course 
of  a  day.  This  condition  of  the  blood  is  impossible  during  life,  and  it 
throws  a  great  responsibility  upon  the  alkalies  of  the  body  for  our  daily 
existence. 

Whitney's  works  on  acidosis  in  relationship  to  the  cause  of  death 
are  important  contributions  to  our  literature.  Samples  of  blood  were 
taken  from  the  heart  as  soon  as  poossible  after  life  was  extinct.  The  Van 
Slyke  method  was  used  for  determination.  Out  of  forty  cases  examined, 
dying  of  various  diseases,  all  except  three  showed  a  more  or  less  marked 
acidosis  at  the  time  of  death.  In  many  of  the  cases  this  acidosis  was  so 
severe  that  it  alone  was  sufficient  to  cause  respiratory  paralysis.  In 
other  cases  the  acidosis  was  not  sufl&ciently  high  to  have  been  the  im- 
mediate cause  of  death.  Infection  seemed  to  have  a  marked  influence 
in  causing  acidosis.  However,  a  patient  may  have  a  marked  infection 
and  show  no  acidosis,  providing  his  powers  of  elimination  are  active. 
As  causes  of  increased  acid  production  in  nephritis,  the  toxemia  of  the 
active  parenchymatous  form  is  itself  operative;  infection  is  an  even 
more  powerful  factor. 


152  Lymphatics 

Non-Protein   Nitrogen   on   Blood    (NPN) 

Non-protein  nitrogen  is  a  term  applied  to  the  nitrogen  remaining 
after  all  the  proteins  have  been  precipitated  out  of  the  blood.  The 
N.  P.  N.  substances  in  the  blood  are  urea,  uric  acid,  ammonia,  creatin, 
creatinin,  sugar,  chlorides  in  the  form  of  sodium  chloride  and  choles- 
terol.  The  normal  N.  P.  N.  is  from  25-30  mg.  per  100  cc  blood.  Many 
figures  have  been  given  by  various  workers  for  its  determinations,  as 
well  as  upon  the  state  of  digestion  at  the  time  the  blood  is  drawn  for 
examination.  It  has  been  clearly  demonstrated  that  the  N.  P.  N.  of  the 
blood  rises  and  sinks  like  the  tide,  with  reference  to  absorption  from  the 
digestive  tract.  This  rise  is,  of  course,  not  a  very  great  one,  about  4 
mg.  per  100  cc  of  blood,  but  it  is  sufficient  to  necessitate  a  variable  figure 
for  the  normal  value  of  N.  P.  N. 

As  the  kidney  is  the  great  regulator  of  the  composition  of  the  blood, 
maintaining  a  practically  constant  level  of  the  N.  P.  N.,  it  is  in  disorder 
of  this  organ,  especially,  that  most  is  to  be  expected  from  a  study  of  the 
variations  in  non-protein  nitrogen  of  the  blood.  Nimierous  workers 
have  shown  that,  in  the  majority  of  cases,  the  N.  P.  N.  increases  with  an 
increasingly  severe  nephritis.  In  cases  tending  toward  uremia,  or  show- 
ing actual  uremia,  the  values  of  N.  P.  N.  are  markedly  increased,  reach- 
ing  in  some  cases  as  high  as  350  mg.  or  over  for  100  cc  of  blood.  This 
rarely  is  seen  in  conditions  other  than  uremia,  so  that  this  factor  assumes 
great  importance  in  diagnosis. 

Further,  the  prognostic  value  of  this  examination  is  phown  in  that 
patients  with  high  non-protein  nitrogen  do  not,  as  a  rule,  survive  for  a 
very  long  period.  Another  valuable  point  in  the  study  of  this  factor, 
is  that  it  furnishes  a  guide  to  the  proper  diet  to  be  allowed  nephritics,  as 
cases  of  high  retention  require  restriction  of  protein.  Also,  surgical 
operations  should  be  avoided  when  possible,  in  cases  of  high  N.  P.  N. 
Ordinarily,  in  nephritis,  the  less  the  phenolsulphonephthalein  output, 
the  greater  the  amount  of  non-protein  nitrogen  in  the  blood.  However, 
in  chronic  passive  congestion  of  the  kidney,  from  cardiac  insufficiency, 
the  output  of  phenolsulphonephthalein  may  be  markedly  diminished 
without  an  increase  of  non-protein  nitrogen  being  found  in  the  blood. 
Whenever  the  excretion  of  phenolsulphonephthalein  is  decreased,  the 
amount  of  non-protein  nitrogen  in  the  blood  should  be  ascertained,  as 
this  will  indicate  whether  the  fault  lies  with  a  damaged  kidney,  which 
is  impermeable  to  the  dye,  or  whether  the  fault  lies  with  a  damaged 
heart,  which  is  inadequate  to  convey  the  blood  to  its  point  of  exit  from 
the  system. 


Blood  Chemistry  153 

One  hour  after  phenolsulphonephthalein  has  been  injected  inter- 
muscularly,  fifty  per  cent,  should  be  recovered  in  the  urine,  and  eighty- 
five  per  cent,  at  the  end  of  two  hours.  When  only  forty  per  cent,  is 
passed  at  the  end  of  two  houi-s,  (ElHot.  Jour.  A.  M.  A.  June  5,  1915,  Pg. 
1885)  considers  that  not  only  are  the  kidneys  defective,  but  also  there  is 
retention  of  waste  nitrogen  in  the  blood,  and  blood  tests  should  be  made. 
A  single  determination  of  non-protein  nitrogen  of  the  blood  is  not  con- 
clusive unless  a  veiy  large  amount  is  found.  But  gradual  increase  from 
day  to  day  or  week  to  week  shows  danger  of  uremia,  and  uremia  is  not 
a  poison  caused  by  one  poison,  but  many. 

Tillestone  &  Comfort  (Arch.  Int.  Med.  Nov.  1914,  Pg.  620)  give 
the  following  with  reference  to  the  amounts  of  non-protein  nitrogen  found 
in  the  blood : 

30  mg.  per  100  cc  of  Blood  ....  Normal 

30-35  mg.  per  100  cc  Blood ....  Slight  increase 

35-50  mg.  per  100  cc  Blood. . .   Considerable  increase 

50-100  mg.  per  100  cc  Blood. .  .  Great  increase  with  serious  prognosis. 

While  uremic  patients  practically  always  show  nitrogen  retention, 
it  is  interesting  to  note  that  this  is  not  always  the  case  in  puerperal  eclamp- 
sia, unless  there  has  been  a  long  previoiL=  nephritis.  Fehling  saj^s  that 
5%  of  pregnant  cases,  having  an  old  nephritis,  develop  eclampsia.  In 
other  words,  puerperal  eclampsia  may  not  be  a  true  uremia,  as  other 
retained  intoxicants  may  cause  convulsions  besides  those  retained  by 
kidney  insufficiency. 

Gout  and  rheumatism  are  diseases  on  which  the  differential  diag- 
nosis, by  blood  chemistry,  has  thrown  some  light.  In  gout  we  find  a 
chronic  disorder  of  metabolism,  in  which  there  is  an  undue  accumulation 
of  uric  acid  in  the  blood,  whereas  in  rheumatism  there  is  no  such  accumu- 
lation, the  figure  remaining  around  1-3  mgs.  per  100  cc  of  blood.  Folin 
and  Denis  (Jour.  Bio.  Chem.,  1913,  Vol.  XIV,  p.  82)  showed  that  the 
amount  of  uric  acid  in  the  blood,  under  normal  conditions,  varied  from 
0.7-3.7  mgs.  per  100  cc  of  blood.  However,  we  always  find  a  hyperuri- 
cemia in  gout  and  this  condition  is  long  continued  while  in  other  joint 
disorders  the  hyperuricemia  is  transitory.  In  rheumatism  we  find  a 
temporary  increase  in  uric  acid  but  it  will  not  remain  at  this  level  or 
increase  as  it  does  in  gout.  The  obvious  procedure,  therefore,  in  sus- 
pected gout,  is  to  follow  one  examination  with  others  at  interrupted 
intervals.  The  fact  that  we  get  a  diminution  in  the  uric  acid  in  the 
urine  does  not  necessarily  mean  that  we  have  a  hyperuricemia.  For 
a  positive  diagnosis  we  must  look  to  the  blood. 

A  retention  of  uric  acid  in  the  blood  may  be  earlier  evidence  of 
renal  impairment  of -an  interstitial  type  than  the  classical  tests  of  al- 


154  Lymphatics 

buminuria  and  cylindruria.  In  discussing  the  blood  figure  of  chronic 
nephritis,  interstitial  and  parenchymatous  in  variety,  it  will  be  necessary 
to  refer  to  some  of  the  other  facts  of  the  nitrogenous  metabolism. 

In  digestion,  protein  matter  is  broken  down  into  amino-acids,  some 
of  which  are  retained  and  others  are  transformed  into  ammonia  and 
eliminated.  The  greater  part  of  the  nitrogen  in  the  body  comes  from 
the  food,  exogenous,  and  its  final  elimination  takes  place  in  the  form 
of  urea  by  way  of  the  kidneys. 

The  source  of  creatinin  is  almost  entirely  endogenous.  Victor 
Myers  (Jour,  of  Amer.  Med.  Science,  May  1919,  P.  674)  gave  a  very 
complete  article  on  creatinin  determination.  The  values  he  obtained  are: 

1-2  mgs.  per  100  cc.  blood normal 

3  mgs.  per  100  cc.  blood rather  serious 

4  mgs.  per  100  cc.  blood very  serious 

5  mgs.  per  100  cc.  blood fatal 

Theoretically,  the  increase  in  creatinin  of  the  blood  should  be  a 
better  index  of  the  decrease  in  the  permeability  of  the  kidney  than  the 
increase  in  urea,  for  the  reason  that  the  source  of  creatinin  is  entirely 
endogenous  and  very  constant.  Urea,  on  the  other  hand,  is  largely 
exogenous,  under  normal  conditions,  and  its  formation  subject  to  greater 
fluctuations.  For  this  reason  it  is  evident  that  a  lowered  nitrogen  in- 
take may  reduce  the  work  of  the  kidney  in  eliminating  urea  but  it  will 
not  affect  the  creatinin  to  any  great  extent.  It  is  only  logical,  therefore, 
for  us  to  look  to  creatinin  to  furnish  a  satisfactory  criterion  as  to  the 
deficiency  of  the  excretory  power  of  the  kidney  and  as  a  most  reliable 
means  of  following  the  terminal  course  of  the  disease.  The  prognostic 
value  of  5  mgs.  of  creatinin,  or  more,  in  the  blood  is  very  definite.  It 
warns  of  the  fatal  termination  of  the  disease  invariably. 

By  the  examination  of  the  urine  alone,  a  great  many  conditions  go 
unnoticed  and  a  favorable  prognosis  is  given  when  the  patient's  chances 
for  recovery  may  be  very  small. 

The  normal  amounts  of  the  Non-Protein-Nitrogen  constituents  of 
the  blood  are : 

N.  P.  N 25-30  mgs.  per  100  cc.  blood 

Urea  Nitrogen 12-15  mgs.  per  100  cc.  blood 

Uric  Acid 0.7-3.7  mgs.  per  100  cc.  blood 

Creatinin 1-2.5  mgs.  per  100  cc.  blood 

Creatin 5-10  mgs.  per  100  cc.  blood 

Sugar 0.08-0.12% 

Chloride  as  Sodium  Chloride 0.65% 

Cholesterol 0.15% 


156 


Lymphatics 


EVELYN  R.  BUSH,  D.  O. 
Louisville,  Ky. 


CHAPTER  NINE 

THE  EFFECTS  OF  EXERCISE  ON  THE  LYMPHATICS 

Evelyn  R.  Bush,  D.  O.,  Louisville,  Ky. 

The  two  great  functions,  respiration  and  circulation,  are  made  more 
active  through  the  physiological  effect  of  exercise.  It  is  impossible  for 
any  of  the  organic  functions  of  the  body  to  be  separated  from  the  result 
of  the  work  of  the  muscles.  The  increased  frequency  of  the  pulse  rate, 
and  hence  the  quickened  blood  current  during  exertion,  is  the  result  of 
muscular  contraction.  It  is  observable  that  every  organ  during  activity 
has  a  greater  amount  of  lymph  bathing  its  tissues,  than  during  a  quies- 
cent state. 

As  we  study  and  analyze  the  results  of  exercise,  we  are  forced  to 
realize  that  the  daily  regular  and  frequent  repetition  of  muscular  move- 
ments cause  an  increased  activity  in  the  venous,  arterial  and  lymphatic 
system,  thus  relieving  the  tissues  of  congestion,  and  bathing  them  in 
nutrition,  and  by  these  changes  improve  and  protect  the  system  from 
various  disorders. 

The  same  fact  is  observable  in  the  lungs — by  exercise  the  improved 
circulation  results  in  greater  power,  i.  e.,  greater  regularity  and  control  in 
in  performing  movements,  greater  development  and  strength. 

The  heart  also  gains  by  well-directed  regular  exercise.  It  becomes 
less  excitable  upon  exertion.  The  beginner  in  exercise  shows  various 
disturbances  upon  the  slightest  movements,  but  not  so  the  one  who  has 
had  training  regularly.  The  improved  heart  action  furnishes  a  better 
flow  of  lymph  to  its  ultimate  destination. 

The  man  who  accustoms  his  body  to  regular  work  improves  his 
organs,  just  as  a  laborer  can  do  better  work  with  better  tools.  The 
man  who  systematically  trains  his  body  gets  better  work  out  of  it  and 
better  service  for  humanity. 

Man  is  restricted  by  mental  intensity  and  muscular  restraint.  This 
restraint  interferes  with  and  defeats  Nature.  She  not  only  cannot  ex- 
press herself  through  such  a  tense,  high-keyed  instrument,  but  such 
restraint  causes  great  waste  of  nerve  energy  and  also  interferes  with 
flow  of  lymph.  To  get  rid  of  this  nerve  tension  use  relaxing,  resting 
movements. 

Daily  invigorating  and  relaxing  exercises  are  necessary  to  promote 
the  onward  flow  of  lymph  towards  its  final  discharge  into  the  blood. 
Apparatus  is  unnecessary;  no  special  clothing  is  required;  exercise  taken 


158  Lymphatics 

nude  before  mirror  is  best.  Ten  minutes  in  morning  and  fifteen  or 
twenty  at  night,  after  the  form  of  exercise  is  learned  and  old  habits 
broken. 

Wc  should  consider  exercise  a  part  of  our  daily  routine,  same  as 
we  do  washing  the  teeth,  combing  the  hair,  bathing,  etc. 

The  thread-worn  remark,  "I  haven't  time"  no  longer  holds.  Ef- 
ficiency is  the  commander.  It  takes  no  more  time  to  stand  correctly 
than  it  does  to  "slump-on-one-hip."  It  is  not  a  question  of  time  as  of 
learning  relative  values.  Cause  and  effect  in  the  body  is  the  law.  It  is 
impossible   to   be   structurally  abnormal   and   physiologically   normal. 

Would  an  aeroplane  pilot  try  to  run  a  plane  by  any  laws  other 
than  those  necessary  to  the  perfection  of  the  invention?  He  knows  the 
infinite  amount  of  trouble  he  would  incur  if  he  did  not  first  become  in- 
formed as  to  the  laws  of  the  machine  he  is  to  run.  Yet  how  about  the 
human  machine?  Frequently  all  law  is  disregarded.  The  first  law 
of  all  machines — balance,  equilibrium,  harmonj'^,  adjustment — is  often 
forgotten.  The  human  machine,  if  out  of  balance,  will  not  run  per- 
fectly any  more  than  any  other  machine. 

From  our  osteopathic  point  of  view,  one  of  the  most  important 
causes  of  disease  is  the  maladjustment  of  the  bones  of  the  skeleton. 
Hence,  if  the  framework  is  wrong,  all  else  is  wrong,  the  circulation  in 
the  veins,  arteries  arid  lymphatics  being  among  the  first  to  suffer. 

The  body  poise  is  mechanically  correct  if  the  ankles,  hips  and  spine 
are  correct.  When  the  spine  is  in  correct  position,  all  other  parts,  the 
trunk,  chest,  neck,  head  and  shoulders,  are  in  correct  positions.  There 
is  such  close  co-ordination  between  all  parts  of  the  body  that  if  even 
one  is  out  of  place  then  one  or  all  other  parts  will  suffer. 

The  phase  of  readjustment  which  I  will  discuss  will  be  muscular. 
The  keynote  of  our  profession  is  normality  of  bony  structure.  In  our 
eagerness  to  perfect  alignment  we  sometimes  forget  to  recognize  the 
importance  of  muscular  tonicity;  we  sometimes  forget  that  the  "vis-a- 
torgo",  of  the  power  from  behind,  is  necessary  to  the  onward  flow  of 
lymph.  We  sometimes  forget  that  the  maintenance  of  normal  bony 
structure  is  due  to  the  strength  of  the  ligaments  and  muscles. 

The  different  parts  of  the  body  can  only  be  kept  in  condition  by 
performing  th(^  different  functions  normal  to  them.  The  muscles  in 
performing  their  functions  not  only  improve  their  own  quality  and  tone 
and  keep  the  normal  bony  alignment,  but  they  improve  the  health  and 
strength  of  the  entire  system,  including  brain,  nerves,  heart,  lungs,  pel- 
vic organs,  etc.,  through  the  effect  produced  upon  the  respiration,  the 
venous,  arterial  and  Ijmiphatic  circulation  and  digestion. 


Blood  Chemistry  159 

All  of  our  muscular  work  should  be  based  upon  scientific  principles 
and  in  perfect  harmony  with  natural  laws. 

People  frequently  say,  "I  believe  in  exercise  but  I  am  too  old;  my 
muscles  are  too  stiff,"  never  realizing  they  are  lessening  their  chances 
of  life  by  this  very  inactivity.  As  all  the  tissues  receive  their  food 
through  the  lymph,  then  sluggish  lymph  means  lessened  circulation, 
hence  shorter  Hfe.  Physical  education  should  not  be  Hmited  to  the 
period  of  youth.  Indeed,  those  who  begin  to  feel  the  weight  of  years 
or  rather  the  cripphng  effect  of  bad  physical  habits,  need  the  help  that 
can  be  derived  from  rational  exercises  even  more  than  do  the  young. 

By  regaining  lost  flexibihty  and  youth,  and  learning  to  economically 
use  his  nerve  force,  it  is  possible  for  many  a  person  past  his  prime  to 
make  his  more  advanced  age  his  best  years  physically.  One  cannot  be 
too  old  to  exercise.  So  long  as  we  abide  in  our  bodies,  we  should  strength- 
en them  by  daily  exercise  as  much  as  by  daily  food.  Muscles  that  are 
called  stiff  are  usually  either  tense  or  weak.  Muscles  that  are  not  duly 
exercised  lose  their  shape,  their  firmness  and  their  strength,  due  largely 
to  the  lymph  in  the  lymph  spaces  not  being  sufficiently  stimulated 
through  pressure  by  muscular  contraction.  Nowhere  else  does  this 
muscular  degeneracy  so  rapidly  steal  away  our  health  and  our  efficiency 
as  in  the  waist  muscles.  The  abundance  of  lymphatics  in  this  region  ar- 
rest the  necessity  for  muscular  activity.  A  person  is  years  older  or 
younger  in  appearance,  health  and  efficiency  according  to  the  tone  and 
health  of  these  muscles.  We  might  truly  say,  we  are  healthy  in  propor- 
tion to  the  normality  of  our  lymph  flow.  To  avail  oneself  of  the  oppor- 
tunity of  exercise  is  each  person's  own  responsibility. 

We  must  change  our  habits  of  life,  we  must  change  our  style  of 
dressing.  Great  strides  forward  have  been  made  in  woman's  dress 
lately,  and  soon  we  will  wear  clothing  of  such  a  character  as  to  leave  the 
body  unhampered  and  unrestricted. 

If  the  corset  were  a  necessity  for  the  maintenance  of  health  for 
women,  according  to  the  Divine  Plan,  the  liOrd  in  his  omnipotent  wisdom 
would  have  given  us  one  with  which  to  start  life's  journey.  There  is  no 
more  excuse  for  women  to  wear  coi-sets  than  men,  primarily,  but  the  style 
of  dress  and  lack  of  physical  education  have  been  responsible  for  the  weak 
abdominal  muscles  that  sometimes  demand  artificial  support. 

In  the  measuring  of  man,  where  do  we  stand  physically?  Where  do 
we  stand  in  physical  efficiency?  Just  what  is  our  balance  on  the  ledger 
of  life?  We  are  beginning  to  appreciate  the  vital  importance  of  knowing 
the  physical  examiner's  report.  Why  consider  brains  and  training  of 
other  kinds  and  neglect  the  body? 


160 


Lymphatics 


Plate  XXXV. 


Plate  XXXVI. 


Plate  XXXVI 1. 


Effects  of  Exercise  161 

We  KNOW  mathematics  but  we  do  not  know  that  in  order  to  have 
health,  we  must  have  a  normal  lymphatic  system ;  that  the  lymph  vessel 
has  its  origin  within  the  tissues,  and  carrying,  as  it  does,  the  nutriment  to 
nearly  every  cell  and  tissue  in  the  body,  it  must  be  kept  normally  active; 
that  the  normal  flow  of  lymph  is  essential  and  that  the  "lymph  move- 
ment" is  largely  due  to  muscular  activity. 

It  matters  not  what  the  occupation,  the  habits,  the  conditions,  the 
environment  of  the  individual,  it  is  the  balance  between  the  receipt 
and  expenditure  of  vital  force  which  constitutes  perfect  health. 

We  can  only  maintain  our  normal  physical  standard  of  excellence  and 
efficiency  by  deliberate  and  adequate  care. 

The  body  must  be  developed  with  the  same  care  and  thoroughness 
as  the  mind,  if  it  is  to  stand  the  stress  and  strain  of  life  and  measure  up 
to  one  hundred  per  cent,  efficiency. 

The  highest  aim  of  education  is  to  liberate  the  mind  and  spirit — 
to  set  them  free.  This  means  that  the  body,  the  medium  through  which 
we  reveal  the  intelligence  and  fine  spirit  within,  must  be  made  and  kept 
plastic  and  obedient. 

We  must  learn  to  despise  the  pitiful  restrictions  which  we  have 
allowed  fashion  to  put  upon  us.  We  must  do  away  with  all  restric- 
tions of  the  foot,  waist  and  throat  before  natural  symmetry  of  the  body 
can  be  regained  and  preserved.  We  must  learn  to  admire  the  body  with 
all  its  natural  spontaneous  power  and  pliability,  its  capacity  for  action, 
its  instinctive  unhampered  ease. 

Activity  is  life.  Inactivity  is  disease  and  death.  There  is  nothing 
in  this  wonderful  world  of  ours  quite  so  wonderful,  nothing  quite  so 
beautiful  as  a  perfect  man  or  woman  physically.  And  whether  you 
consider  it  from  an  aesthetic  standpoint,  or  that  of  the  greatest  utility, 
there  is  no  consideration  of  human  life  quite  so  significant,  so  important 
or  so  desirable. 

It  does  not  seem,  therefore,  that  any  well  chosen  care  we  can  Vestow 
on  physical  education  can  be  unimportant  or  undignified,  or  that  anj' 
element  of  culture  is  more  needful  than  the  perfecting  of  our  bodily 
fitness  and  growing  vigor. 

We  American  v/omen  do  not  ask  our  men  to  be  reputable  citizens 
ONLY,  but  to  be  admirable  and  creditable  examples  of  physical  manhood 
as  well. 

By  a  systematic  stimulation  causing  a  thorough  and  complete 
drainage  of  the  lymphatics,  a  vital  resistance  in  the  body  is  built  up  and 
maintained,  which  will  protect  it  and  prevent  infections  of  various 
kinds. 


162 


Lymphatics 


te 


Plate  XXXIX. 


Plate  XXXVIII. 


Plate  XL. 


Effects  of  Exercise  163 

In  health  we  should  take  all  around  activity  which  will  insure  normal 
lymphatic  drainage.  This  spells  Protection  and  Prevention,  for  health 
depends  upon  an  even  control  of  all  parts. 

With  the  installing  of  modern  heating  plants  in  homes,  the  indoor 
clothing  has  been  modified.  Bodily  habits  and  activities  must  adjust 
themselves  to  the  changed  conditions  which  the  last  decades  have 
brought,  if  health  is  to  be  maintained. 

The  necessity  for  increased  activity  is  due  to  the  various  efficiency 
devices,  which  have  replaced  muscle  activity.  The  world  demands 
brain — not  brawn — to  handle  its  problems.  Health  demands  brawn 
as  well  as  brain.  As  the  various  occupations  do  not  furnish  sufficient 
opportunity  for  the  best  development  of  the  body,  exercises,  intelli- 
gently prescribed  and  conscientiously  taken,  just  supply  this  deficiency. 
It  is  as  important  to  study  now  to  maintain  the  greatest  bodily  resist- 
ance, how  to  keep  the  body  immune  to  the  various  ills  which  attack  it, 
as  to  study  disease  itself. 

There  are  practically  few  diseases  which  cannot  be  benefited  by 
exercise,  either  passive  or  resistive.  The  laity  and  many  physicians 
as  well,  are  in  the  habit  of  thinking  of  exercise  only  in  its  strenuous  forms, 
just  as  they  are  thinking  of  Osteopathy  as  a  vigorous  form  of  treatment 
and  suitable  only  for  the  robust. 

It  is  a  question  of  the  intelligence  of  the  physician  who  prescribes 
exercise  on  one  hand,  and  the  skill  of  the  physician  in  giving  the  ad- 
justive  technique  on  the  other.  It  is  knowledge,  ability,  and  judgment, 
not  force,  that  is  needed. 

The  kind  of  exercises,  both  in  quality  and  quantity,  needed  for  the 
growing  individual,  as  well  as  the  adult,  in  various  stages  of  physical 
development,  is  a  problem  that  faces  the  physician  daily.  The  under- 
standing of  the  theory  of  the  different  systems  of  gymnastics;  the  abihty 
to  get  co-operation  from  the  gymnastic  instructor,  who  carries  out  the 
physician's  directions,  just  as  the  nurse  does  in  carrying  out  the  physi- 
cian's instructions;  the  abihty  of  the  physician  to  demonstrate  in  his 
own  body  the  same  normality  of  structure  as  he  professes  to  produce  in 
the  patient,  are  all  problems  to  meet. 

The  average  gj^mnastic  instructor  who  is  able  to  display  well-de- 
veloped muscles,  do  stunts  on  apparatus  which  appall  the  untrained; 
the  niirse  whose  experience  has  given  her  a  great  amount  of  skill,  fre- 
quently handicap  the  physician.  Both,  often  disastrously  presuppose 
their  ability  embraces  the  knowledge  of  pathology  and  symptomatology 
of  disease  which  characterize  the  broader  work  of  the  physician.  If 
the  physician  would  train  his  own  body  to  normality  of  posture,  of  mus- 


164 


Lymphatics 


Plate  XLI. 


Plate  XLII. 


•Plate  XLIII. 


Effects  of  Exercise  165 

ciilar  control;  if  he  would  acquire  some  of  the  skill  of  a  nurse  in  hand- 
ling a  patient,  he  would  get  better  co-operation  and  the  patient  would 
profit.  There  is  a  certain  contention  among  the  gymnasts,  nurses  and 
physicians.  Each  must  know  his  relative  place,  recognizing  that  all 
are  necessary  to  the  goal  of  Health.  Emerson  says:  "How  can  I  hear 
what  you  say,  when  what  you  are  is  forever  thundering  in  my  ears?" 

When  we  consider  that  the  bones  of  the  body  would  fall  apart  if 
it  were  not  for  the  ligaments  and  muscles,  that  the  accuracy  with  which 
the  bony,  articular,  adjacent  surfaces  fit  depends  upon  the  strength  of 
these  ligaments  and  muscles,  there  is  left  only  the  necessity  for  main- 
taining the  normal  strength  of  these  tissues.  It  is  not  a  question  of 
"shall  we  exercise,  but  we  must  exercise." 

Due  to  the  progress  of  civilization,  so  many  of  the  opportunities  for 
muscular  exercise  have  been  taken  away  that  it  will  now  become  a  part 
of  our  course  of  study  how  to  conscientiously  exercise  enough  to  keep 
the  organism  to  its  standard  of  vital  resistance.  So  many  of  the  occupa- 
tional diseases  are  due  to  this  very  lack  of  proper  attention  being  paid 
to  this  phase  of  life;  i.  e.,  to  the  need  of  all  around  exercise. 

The  longer  hours  in  school  for  children,  thus  lessening  the  activity 
normal  to  them ;  the  ever-increasing  modern  devices  which  are  labor- 
saving,  thus  cutting  down  the  opportunity  for  muscular  activity  so 
necessary  to  the  normal  body;  the  increased  demands  for  mental  con- 
centration to  accomplish  more  in  shorter  time,  which  means  further 
expenditure  of  nerve  force;  the  lessened  amount  of  sunshine  and  the 
quantity  of  fresh  air,  are  all  changes  due  to  city  development.  Begin- 
ning  with  the  tot  kept  in  school  for  at  least  five  hours  of  the  day,  to  the 
factory  worker,  the  bookkeeper,  the  stenographer,  and  to  the  various 
forms  of  ever  increasing  sedentary  life — forgetting  that  exercise  is  ever 
fundamental  to  growth  and  health — is  a  situation  which  handicaps  the 
efforts  of  physicians  of  all  schools  today. 

Exercises  should  be  in  line  with  the  natural  functions  of  the  body. 
There  are  methods  in  climbing,  methods  in  jumping,  methods  in  running 
and  walking,  so  it  ever  is  in  exercise — the  method  used  is  all  important. 

The  following  exercises  are  planned  so  as  to  promote  and  restore 
normal  lymphatic  circulation,  thus  increasing  nutrition  and  improving 
the  general  health: 

An  exercise  for  strengthening  abdominal  muscles  and  accelerating 
lymph  flow  through  the  abdomen,  is  done  with  a  weight.  Lie  on  the 
back,  put  as  heavy  weight  (a  book  will  do)  as  can  be  lifted  easily  upon 
abdomen  and  raise  abdomen  up  and  down.  (Plate  35).  Increase  weight 
in  proportion  to  increase  of  strength  of  muscles.  The  back  remains  on 
the  table  constantly. 


166 


Lymphatics 


Plate  XLIV. 


Effects  of  Exercise  167 

A  simple  but  excellent  exercise  for  strengthening  abdominal  mus- 
cles (Plate  36.)  is  to  lie  on  back,  place  book  or  other  weight  across  legs 
at  ankles,  raise  feet,  holding  legs  stiff.     This  strengthens  leg  muscles  also. 

For  increasing  rib  action  use  same  weight  on  chest  (Plate  37) 
raise  and  lower  in  the  same  manner. 

For  loosening  muscles  of  the  spine  the  following  is  most  excellent: 
(Plate  38)  Place  the  clasped  hands  at  the  occiput  and  with  strong 
pressure  force  the  chin  to  the  neck.  Begin  rolling  the  head  and  trunk 
forward  and  downward  as  though  you  could  roll  the  body  into  a  ball. 
Continue  the  rolling  movement  as  far  as  possible  until  you  have  gained  a 
decided  stretch  on  the  sciatic  nerve  or  make  the  head  touch  the  legs, 
(Plate  39) .     Returning  to  normal  position  slowly,  breathing  constantly. 

This  exercise  (Plate  40)  is  for  the  abdomen,  back  and  ribs,  and 
is  very  far-reaching  in  its  effects:  Sit  upon  a  stool,  and  bend  the  body 
backward  until  the  head  is  near  the  floor.  Then  rise  slowly  to  a  sitting 
position.  The  feet  may  be  kept  on  the  floor  by  putting  toes  under  a 
chair  or  a  strap  attached  to  the  floor  for  the  purpose. 

Clasp  hands  at  back  of  neck,  (Plate  41)  stride  forward  on  left 
foot,  bend  body  forward  until  chest  is  on  thigh.  A  comprehensive  and 
effective  movement  that  can  be  varied  in  several  ways  to  take  in  all  parts 
of  the  body.  A  good  variation  is  to  extend  hands  above  head  instead  of 
clasping  in  back  of  neck,  and  take  same  movement  as  described. 

Breathing  may  be  considered  the  most  important  of  all  the  func- 
tions of  the  body.  All  other  functions  depend  upon  it.  Man  may  ex- 
ist some  time  without  eating,  a  shorter  time  without  drinking,  but  with- 
out breathing  his  existence  may  be  measured  by  minutes.  The  ma- 
jority of  women  do  the  upper  chest  breathing  only.  The  majority  of 
men  do  the  lower  mid-chest  breathing.  I  will  take  up  with  you  the 
different  areas,  the  upper,  mid-chest  and  diaphragmatic,  and  how  to 
gain  control  of  them  and  the  freeing  of  the  ribs,  which  is  essential  to 
normal  breathing : 

The  patient  will  lie  on  the  table,  on  the  back,  knees  flexed.  Take 
an  ordinary  breath  and  exhale.  After  taking  a  breath  lift  the  chest  wall, 
thus  drawing  in  the  abdomen.  Do  this  to  the  count  of  1 ;  to  the  count 
of  2  lift  the  abdomen.  This  will  draw  in  the  chest.  Alternate  rapidly 
to  the  count  of  1-2,  1-2,  1-2.  In  this  way  you  will  get  an  internal  ab- 
dominal massage  better  than  anyone  can  give  you.  Every  organ,  every 
particle  of  tissue  within  is  lifted  and  vibrated  by  this  movement.  Ex- 
treme tenderness  may  be  felt  at  first.  Do  it  slowly  but  more  rapidly 
as  you  become  more  skillful  and  gain  in  control.     To  make  it  more  diffi- 


168 


Lymphatics 


Plate  XLV. 


Plate  XLVI. 


Effects  of  Exercise  169 

cult,  take  a  deep  breath  abdominally — I  say  abdominally  in  order  to 
make  it  clearer.  Muscularly  distend  the  abdomen  as  far  as  possible. 
Then  take  the  exercises  as  above  described  with  the  count  of  1-2.  Plac- 
ing the  hands  in  front  of  the  lower  ribs  in  the  diaphragmatic  area,  say 
the  word  "Yawn,"  drawing  in  the  breath  and  feeling  the  distention  in 
the  diaphragmatic  area  only.  This  will  be  quite  difficult  to  get  and  will 
never  be  done  perfectly  unless  you  stand  on  the  balls  of  the  feet  with 
the  chest  well  lifted  and  abdomen  drawn  in.  Place  hands  on,  sides  in 
diaphragmatic  area  and  repeat  "Yawn,"  getting  lateral  movement 
in  the  ribs. 

Place  the  hands  in  the  mid  chest,  laterally,  taking  in  the  breath 
and  forcing  the  ribs  out.  Hold  the  diaphragmatic  and  mid  breath  taken 
and  feel  the  upper  part.  Try  these  different  areas  by  placing  your  hands 
upon  them  separately  until  you  have  gained  control  and  until  you  can 
breathe  in  any  part  separately;  then  combine. 

Roll  over  on  to  shoulders  and  head,  support  the  hips  with  hands, 
elbows  resting  upon  the  floor,  (Plate  42).  Alternate  leg  movement, 
similar  to  riding  a  bicycle.  This  exercise  can  be  varied  by  flexing  both 
knees  down  to  chest;  straighten  and  flex  several  times.  Also  try  to 
touch  floor  over  head.     Alternate  feet  and  do  it  with  both  feet  together. 

Plate  43.  Bend  the  body  at  right  angles  to  legs.  Bend  the  right 
knee  (if  unable  to  keep  straight)  and  touch  the  floor  in  front  of  right 
toes,  at  same  time  extend  left  arm  upward  and  backward.  Alternate 
same  movement  with  left, 

Plate  44.  Bend  body  sidewise  keeping  it  in  same  line  as  when  erect 
and  with  right  hand  touch  outside  of  leg  as  near  knee  as  possible.  Flex 
left  arm  at  elbow  having  closed  hand  high  in  axilla.  Alternate  move- 
ment with  opposite  side. 

Assume  squatting  position  as  shown  in  Plate  45  with  clasped  hands 
well  back  between  legs;  rise  to  erect  position  with  hands  extended  over- 
head; bend  backward  from  the  waist,  lifting  and  rounding  out  chest 
as  shown  in  Plate  46. 

Great  attention  should  be  paid  to  the  vasomotor  hygiene.  Much 
of  life  depends  upon  the  proper  functioning  of  this  system.  Muscular 
activity,  the  control  of  the  emotions,  are  both  dependent  upon  it  for 
their  well  being. 

The  insane  asylums  furnish  us  with  many  examples  of  perverted 
emotions  due  to  the  lack  of  a  proper  circulation  to  the  various  organs. 
Over-wrought  emotions,  wild  delusions,  vivid  hallucinations,  are  not 
often  found  among  those  whose  muscles  are  firm  and  vigorous. 


170  Lymphatics 

The  health  of  the  vasomotor  system  depends  largely  upon  proper 
muscular  exercise.  The  cold  hands  and  feet  of  the  student  are  often  due 
to  this  lack  of  exercise.  Other  irregularities  occur  when  the  system  is 
not  kept  in  proper  tone. 

The  circulation  of  the  lymph  is  of  the  greatest  importance  and  is 
chiefly  carried  on  by  muscular  contraction.  The  lymph  spaces  are 
squeezed  by  the  pressure  and  the  fluid  is  forced  onward.  Exercise  has- 
tens this,  circulation. 

All  rtspiratory  movements  assist  in  drawing  the  lymph  onward,  as 
they  assist  the  blood  current  to  move  more  evenly  and  normally  toward 
the  heart.  It  is  quite  probable  that  the  muscular  fibres  in  the  walls  of 
the  lymphatics  themselves  have  a  rhythmical  contraction.  The  con- 
tractions of  the  muscular  fibres  of  the  villi  appear  to  further  the  chyle 
movement  from  the  lacteals  into  the  valvular  lymphatics.  As  the  lymph 
vessels  gradually  unite  into  the  larger  ones,  an  increased  pressure  must 
result,  thus  further  assisting  in  its  onward  flow. 

There  are  nearly  seven  hundred  lymph  nodes  in  the  body.  The 
greater  number  lie  in  the  chest  and  belly  cavities,  with  a  few  in  the  neck, 
face  and  limbs,  but  some  in  nearly  every  part  of  the  body. 

AU  tissues  of  the  body  derive  their  nutrient  material  from  and  ex- 
crete their  waste  products  into  the  lymph.  The  oxj'^gen  and  food  ab- 
sorbed into  the  blood  pass  through  the  capillary  walls  into  the  lymph, 
bathing  all  tissues. 

Knowing  this,  effective  exercises  can  be  planned  which  will  func- 
tion for  each  part. 


CHAPTER  TEN 

PART  ONE— LYMPHATIC  GLANDS  OF  THE  NECK 

H.  L.  Collins,  D.  O.,  Chicago 

Lymphatic  glandular  enlargements  of  the  neck  may  be  divided 
into  groups  for  descriptive  purposes.  First  group  Non-tubercular  cer- 
vical  adenitis 

-p,  .  ,         i  from  focal  infection  of  nasopharynx,  mouth  and  face, 
I  jaws,  teeth,  middle  ear,  mastoid,  salivary  glands,  etc.) 

Clinically. 

This  type  may  or  may  not  have  an  elevation  of  temperature  and 
polymorphonuclear  leucocytosis,  depending  largely  upon  virulence  of 
organism  and  extent  of  involvement.  However,  if  there  is  a  constant 
increase  of  temperature  and  an  increase  of  the  polynuclears,  it  is  signifi- 
cant  of  this  variety  of  cervical  adenitis. 

Particularly  is  this  prone  to  occur  if  there  is  a  rapid  increase  in  size 
of  this  type,  for  they  then  undergo  necrosis  and  suppuration. 

This  train  of  circumstances  is  not  characteristic  of  the  tubercular 
type  and  is  useful  as  a  differential  diagnostic  point. 

If  these  glands  do  not  progress  to  suppuration  they  rarely  attain  a 
very  large  size  and  though  occasionally  isolated  nodes  are  observed  (the 
size  of  a  bean)  over  a  long  period  of  time,  the  tendency  is  for  them  to  be 
transitory.  In  other  words,  those  which  do  not  develop  to  a  larger  size 
(say  the  size  of  a  walnut)  rarely  suppurate  and  soon  return  to  their  nor- 
mal size. 

Second  Group. 

Tubercular  cervical  adenitis  or  "scrofulous  neck  swellings"  are 
the  next  most  common.  The  proportion  of  these  two  groups  are  ap- 
proximately five  of  the  first  group  (considering  those  which  go  on  to 
suppuration)  to  one  of  the  second  group. 

The  Etiology. 

The  mode  of  infection  is  very  similar  to  that  of  group  1,  but  the  tu- 
bercle bacilli  being  the  organism  present.  The  structures  of  the  mouth, 
nasophaiynx  and  larynx  being  the  primary  foci  from  which  the  lymph 
nodes  are  involved  secondarily.  Chief  among  these  are  tuberculosis 
of  tonsils  and  adenoids  and  a  great  many  cases,  no  doubt,  are  directly 
infected  through  mucous  membrane  upon  which  is  left  no  clinical  trace 
of  tuberculosis.  Wright's  description  of  this  latter  process  seems  to  be 
quite  logical.  It  has  been  demonstrated  experimentally  and  observed 
cHnically.  The  mucous  membrane  absorbs,  the  lymphoid  tissue  har- 
bors, and  the  lymph  channels  carry  the  tubercle  bacilli. 

—171— 


172  Lymphatics 

Clinically. 

Tho  tubercular  nodes  as  a  rule  have  a  tendency  to  attain  a  larger 
size  than  those  in  group  1,  and  do  not  undergo  suppuration  as  quickly. 
To  illustrate,  take  two  nodes  of  the  same  size  (the  size  of  a  walnut)  one 
in  each  class.  The  one  in  class  1  will  develop  to  its  size  and  suppurate 
in  days,  while  the  one  in  group  2  will  take  weeks  before  it  will  attain  the 
size  of  a  walnut  and  abscess  formation  occur. 

The  temperature,  if  elevated  at  all,  is  more  apt  to  be  the  character- 
istic evening  rise  and  morning  fall,  the  increase  in  white  blood  cells,  due 
to  lymphocytosis  rather  than  multiplication  of  polynuclear  leucocytes. 

Von  Pirquet's  test  for  tuberculosis  in  young  children  may  also  be 
of  help  in  differential  diagnosis,  particularly  if  it  is  negative.  The  above 
points  or  rules  are  of  course,  not  infallible ;  they  vary  with  the  individual 
case,  stage  of  involvement  and  complications,  but  as  a  whole  they  are 
characteristic  of  the  majority  of  uncomplicated  case?  of  tubercular  cer- 
vical adenitis. 

It  is  not  the  purpose  to  discuss  here  the  probable  outcome  of  tu- 
bercular cervical  adenitis  with  and  without  various  modes  of  treatment, 
but  because  of  the  prevalency  and  importance  of  this  malady,  it  is  de- 
serving of  a  little  further  mention. 

There  is  a  possibility  of  the  local  tubercular  process  in  the  neck  be- 
coming disseminated,  most  frequent  of  which,  of  course,  is  the  pul- 
monary involvement.  The  very  probable  local  disfigurement  as  a  re- 
sult of  cold  abscess  formation,  fistula,  etc.,  which  is  much  more  prone 
to  occur  under  any  other  line  of  treatment  than  complete  excision.  The 
complete  excision  should  be  done  as  soon  as  the  diagnosis  is  made,  and 
an  early  diagnosis  is  importa,nt. 

Third  Group. 

Lymphatic  enlargements  as  a  result  of  old  syphilitic  infection.  The 
posterior  cervical  nodes  are  most  commonly  involved  of  the  neck  lym- 
phatics. They  rarely  attain  a  verj'  large  size  unless  mixed  infection  is 
present,  and  syphilis  of  cervical  nodes  is  usually'  associated  with  the  same 
type  of  enlargements  of  lymphatics  in  axilla,  inguinal  region  and  above 
the  elbow.  They  rarely  suppurate  and  are  present  for  a  long  period  of 
time.  The  blood  Wasserman  examination,  of  course,  is  of  value  here  in 
making  a  diagnosis. 

Fourth  Group. 

Hodgkin's  disease  or  Pseudoleukemia.  This  fortunately  is  not  very 
fre(juent  and  unfortunately  most  always  fatal.  It  does  not  respond  to 
the  Von  Pirquet's  test,  and  rarely  suppurates.  Clinically,  it  can  be 
divided  into  two  stages.     In  the  first  stage  there  are  no  signs  except  a 


Glands  of  the  Neck  173 

mass  of  nodes  which  are  in  most  cases  in  the  neck  and  the  general  health 
seems  to  be  surprisingly  good.  In  the  second  stage,  groups  of  nodes  may- 
be involved  almost  any  where,  axilla,  mediastinum,  inguinal  region,  etc., 
steadily  increasing  in  size,  this  accompanied  with  an  anemia  which  be- 
comes progressively  worse. 

Various  forms  of  treatment  have  been  advocated,  chief  among  which 
are  X-ray,  radium  and  surgery.  In  the  first  stage,  surgery  seems  to 
offer  the  best  means  of  delaying  the  steady  progress  of  the  disease.  Af- 
ter generalization  or  second  stage,  the  most  that  is  warranted  by  way  of 
operation  is  removal  of  a  node  for  diagnosis  and  further  surgery  to  do 
what  is  possible  for  mechanical  interference  with  respiration  or  de- 
glutition, such  as  a  tracheotomy  or  excision  of  cervical  nodes  if  the  diffi- 
culty is  due  to  the  neck  glands  and  not  those  in  the  mediastinum. 

Fifth  Group. 

Cystic  lymphangioma  is  very  rare  and  often  attains  a  verj'^  large 
size,  may  be  stationary  in  size  for  some  time,  and  then  suddenly  begins 
to  increase;  most  common  in  youth  and  early  adult  life. 

Lymphosarcoma  is  another  rare  condition  and  is  more  frequently 
diagnosed  by  microscopic  section  than  clinically. 

Note:  Other  cysts  and  tumors  of  the  neck  such  as  bronchial, 
parotid  and  thyroglossal  cysts,  hj-groma  colli,  tumors  of  the  carotid 
body,  enlargements  of  the  thyroid  and  aneurism  must  be  considered  at 
times  in  a  differential  diagnosis. 

All  the  above  cases,  both  surgical  and  non-surgical,  should  have 
osteopathic  care,  particuularly  directed  to  bony  lesions  and  improving 
constitutional  condition. 

That  variety  of  cervical  adenitis  which  is  non-specific  and  non- 
suppurating,  in  addition,  should  be  cared  for  along  the  lines  advised  by 
Dr.  Deason. 

Briefly  summing  up  the  therapeutic  indications  for  all  the  above 
cases,  is  to  treat  conservatively  with  recognized  osteopathic  care,  insti- 
tuting surgery  when  indicated  and  then  post -operative  osteopathic  work 
to  accomplish  the  maximum  normalization  possible. 


C.  PAUL  SNYDER,  D.  O. 
Philadelphia,  Pa. 


CHAPTER  TEN 

PART  TWO— THE  LYMPHATICS  OF  THE  CHEST 

C.  Paul  Snyder,  D,  O.,  Philadelphia,  Pa. 

Professor  of  Cardio-Vascular  and  Respiratory  Diseases,   Philadelphia 

College  of  Osteopathy 

The  workings  of  the  lymphatics  of  the  chest  are  hidden  from  us, 
except  as  they  are  manifested  to  us  through  disease. 

The  lymphatics  of  the  lung  take  their  origin  from  the  pulmonary 
lobes,  while  others  take  their  origin  in  the  fine  connective  tissue  network. 
The  lymphatics  of  the  visceral  pleura  join  with  those  draining  from  the 
lobes  of  the  lung  surface,  and  form  the  superficial  collecting  trunks  ter- 
minating in  glands  at  the  root  of  the  lung.  The  deep  trunk  is  made  up 
of  the  lymphatics  from  the  deeper  lobes  and  those  of  the  bronchi ;  the 
latter,  having  free  communication  with  the  surface  of  the  organ,  termi- 
nate in  the  peribronchial  lymphatics,  which,  accompanied  by  the  bronchi 
and  vessels,  terminate  in  the  hilum. 

The  lymphatics  of  the  pleura  offer  an  interesting  study  in  drainage, 
the  pleura  being  a  closed  serous  cavity,  the  inner  surface  being  lined  with 
endothelium,  the  costal  and  parietal  portions  being  in  close  contact. 
It  is  lubricated  by  serous  secretions  and  is  well  supplied  with  blood  ves- 
sels and  lymph. 

The  lymphatics  are  formed  in  two  series,  one  beneath  the  endo- 
thelium, the  other  in  the  cellular  portion  adjoining  the  pleura,  both 
having  free  communication.  As  previously  indicated,  the  visceral  por- 
tion joins  the  lymph  draining  from  the  lobe  surface  and  forms  the  super- 
ficial collecting  trunk  which  terminates  in  the  hilum  of  the  lung.  The 
costal  portion  of  the  parietal  layer  is  well  drained  by  the  deep  intercostal 
lymphatics,  and  these  terminate  in  the  mammary  glands  and  vessels. 

The  communication  of  the  deep  with  the  superficial  intercostal 
lymphatics  and  the  free  communication  of  the  latter  with  the  lymphatics 
of  the  chest  explains  the  involvement  of  the  axillary  lymphatics  in  thor- 
acic disease. 

The  lymphatics  of  the  pleural  and  parietal  surfaces  of  the  dia- 
phragm communicate  freely.  Infection  passing  from  one  serous  sac  to 
the  other  can  be  explained  in  this  manner. 

Poirier,  in  his  works  on  lymphatics,  explains  the  frequency  of  pleur- 
isy as  a  sequel  to  abscess  and  infection  of  the  liver  as  due  to  the  fact  the 
lymphatic  vessels  from  the  liver  pass  directly  to,  and  drain  into,  the  sub- 
pleural  lymphatics  of  the  diaphragm. 

—175— 


176 


Lymphatics 


Plate  XLVII.  Lymph  Nodes  in  relation  to  Larynx,  Trachea  and  Bronchi. 
The  uppermosi  node  is  the  pre-tracheal.  This  new  X-ray  effect  to  illus- 
trate the  transparency  of  the  various  tissues  will  be  carried  out  from  time 
to  time.  Note  the  nodes  on  the  bronchioles  and  the  possibility  of  infec- 
tion traversing  the  entire  laryngeal,  tracheal  and  bronchial  regions. 


Chest      .  177 

Treatment  for  drainage  and  circulation  of  the  Thorax. 

In  cases  of  pneumonia  and  alUed  conditions,  there  is  one  master 
treatment  which  accompHshes  amazing  results.  This,  I  term  the  "make 
and  break"  movement.  With  one  hand  on  the  heads  of  the  ribs  pos- 
teriorly and  the  other  on  the  ribs  anteriorly,  spring  the  ribs  rhythmically 
in  a  line  with  their  angle,  alternating  the  pressure  from  hand  to  hand. 

To  promote  vaso-dilatation,  sit  down  beside  the  patient  with  the 
hands  at  the  2nd  and  3rd  dorsal  vertebrae.  Exert  pressure  enough  to 
almost  raise  the  patient  from  the  bed  yet  not  quite  do  so.  Alternately 
relax  and  inhibit  for  10  to  15  minutes,  repeating  as  the  case  necessitates. 
Then,  standing  at  the  head  of  the  bed,  grasp  the  neck  as  low  down  as 
possible  so  as  to  get  straight  traction  on  the  2nd  dorsal.  Make  and 
break  for  dilatation  of  the  lung  arterioles.  Direct  pressure  movements 
downward  and  backward  over  the  sternum  and  upper  seven  ribs  on  each 
side,  the  patient  lying  on  his  back,  are  very  efficacious  in  stimulating 
the  lymphatics. 


C.  C.  REID,  M.  D.,  D.  O. 
Denver,  Colo. 


CHAPTER  ELEVEN 

PART  ONE— LYMPHATICS  OF  THE  EYE,  EAR,  NOSE 

AND  THROAT 

C.  C.  Reid,  M.D.,  D.O.,  Denver,  Colorado 

A  healthy  lymphatic  flow  is  essential  to  the  life  and  function  of 
every  important  tissue.  The  large  lymphatic  vessels  empty  into  veins. 
The  vessels  start  with  capillaries.  The  Ijnnphatic  system  is  composed 
of  superficial  and  deep  lymphatic  vessels  with  many  lymphatic  nodes 
scattered  throughout  the  body.  The  lymphatic  vessels  are  thinner- 
walled  than  the  veins.  They  do  not  have  anastomoses  except  through 
lymphatic  nodes. 

All  lymphatic  vessels  have  valves.  The  lymphatic  nodes  inter- 
posed in  the  lymphatic  system  have  the  function  of  counteracting  and 
destroying  poison.  Most  of  the  lymph  traverses  some  nodes  before 
entering  the  veins.  The  largest  lymphatic  nodes  are  only  about  three 
centimeters  in  diameter. 

Quite  large  lymphatic  stems  are  found  on  each  side  of  the  head 
and  neck  and  in  the  abdominal  viscera,  into  which  the  lymph  is  gath- 
ered and  emptied  into  the  veins  of  the  lower  neck  or  upper  thorax.  There 
are  seven  large  lymphatic  stems,  three  of  which  unite  to  form  the  thor- 
acic duct  which  also  receives  two  other  stems.  The  thoracic  duct  begins 
at  the  level  of  the  second  lumbar  vertebra  and  ascending  upward 
empties  into  the  left  subclavian  vein.  It  receives  the  lymphatic  stem 
that  drains  the  left  side  of  the  head  and  neck.  The  right  lymphatic 
duct  empties  into  the  right  subclavian  vein. 

The  right  jugular  lymphatic  trunk  drains  the  right  side  of  the  neck 
and  head.  It  originates  from  the  deep  cervical  nodes.  The  right  sub- 
clavian trunk  originates  from  the  right  axillary  nodes  and  carries  the 
lymph  from  the  right  arm.  The  right  bronchomediastinal  trunk  origi- 
nates from  the  bronchial  and  mediastinal  nodes.  It  drains  the  right 
thoracic  wall,  right  lung,  the  heart,  esophagus  and  part  of  the  liver. 

Lymphatic  Nodes  of  the  Head  and  Neck 

1.  Under  the  skin  upon  the  insertion  of  the  sternocleidomastoid 
muscle,  which  is  back  of  the  ear,  are  located  two  or  three  small  lymphatic 
nodes.  The  lymphatic  capillaries  gather  into  these  nodes  from  the 
posterior  auricular  region. 

2.  Just  back  of  the  posterior  auricular  nodes  upon  the  insertion  of 
the  trapezius  muscle  are  usually  one  or  two  small  nodes  which  drain 
the  occipital  region  and  send  efferent  lymphatic  vessels  through  the 
superficial  cervical  nodes. 

—179— 


180  Lymphatics 

3.  The  parotid  gland  lies  in  front  and  below  the  external  auditory- 
canal  superficially.  Upon  this  gland  just  under  the  skin  and  in  front  of 
the  ear  are  three  or  four  small  anterior  auricular  nodes.  Capillaries  from 
the  temporal  region  terminate  in  these  nodes  by  giving  efferent  vessels 
to  the  superficial  cervical  or  submaxillaiy  nodes. 

4.  Within  the  large  parotid  gland  are  found  a  few  lymphatic  nodes. 
The  lymphatic  capillaries  from  the  eyelids,  from  the  external  ear  and 
from  the  gland  itself  gather  into  these  parotid  nodes.  Efferent  vessels 
from  the  parotid  nodes  pass  to  the  superficial  cervical  and  superior  deep 
cervical  nodes. 

5.  Deep  facial  nodes  are  found  upon  the  buccinator  muscle  and 
in  the  lateral  wall  of  the  pharynx.  These  nodes  receive  the  deep  lym- 
phatic vessels  of  the  face  coming  from  the  orbit,  nose,  palate,  cheeks 
and  pharynx.     They  join  with  the  deep  cervical  nodes. 

6.  Just  beneath  the  mandible  and  between  that  and  the  digastric 
muscle  are  eight  or  ten  quite  large  lymphatic  nodes.  These  are  known 
as  the  submaxillary  lymphatic  nodes.  Just  anterior  to  these  resting 
on  the  under  surface  of  the  mylohyoid  muscle  are  the  submental  nodes. 
These  nodes  drain  the  anterior  part  of  the  face  and  the  chin. 

7.  The  submental,  submaxillary  and  deep  cervical  nodes  receive 
most  of  the  lymph  drainage  from  the  tongue.  Sometimes  there  are 
found  on  the  hypoglossal  muscle  one  or  more  small  lymphatic  nodes 
that  receive  part  of  the  drainage  from  the  tongue  and  send  efferent  ves- 
sels to  the  submaxillary  and  submental  nodes. 

8.  The  superficial  cervical  nodes  are  found  just  under  the  pla- 
tysma  myoides  muscle  and  lie  upon  the  sternocleidomastoid  mostly 
along  its  posterior  body  and  at  the  inferior  border  of  the  parotid  gland 
in  the  anterior  region  of  the  neck.  They  receive  the  capillary  drainage 
from  the  region  of  the  neck  in  which  they  are  situated.  They  also  re- 
ceive efferent  vessels  from  the  anterior  and  posterior  auricular  nodes, 
the  occipital  and  the  parotid  nodes.  They  terminate  with  vessels  in 
the  deep  cervical  nodes. 

9.  Ten  or  fifteen  nodes  are  found  in  the  upper  cervical  region  along 
the  internal  jugular  vein.  These  are  known  as  the  superior  deep  cervical 
nodes.  They  collect  the  lymphatic  capillary  drainage  from  the  cranium 
and  receive  vessels  of  the  facial,  parotid  and  submaxillary  nodes.  They 
also  receive  drainage  from  the  pharynx,  tympanum,  Eustachian  tube, 
inner  ear,  part  of  the  thyroid  gland  and  larynx. 

10.  In  the  supraclavicular  fossa  and  around  the  lower  part  of  the 
internal  part  of  the  jugular  vein  are  the  inferior  deep  cervical  nodes. 
They  receive  efferent  branches  from  the  superior  cervical  nodes,  also 
branches  in  the  lower  trachea  and  esophagus.     Most  of  the  drainage  from 


Eye,  Ear,  Nose  and  Throat  181 

the  head  and  neck  passes  through  the  inferior  deep  cervical  nodes.  The 
superior  and  inferior  deep  cervical  lymphatic  vessels  join  with  the  super- 
ficial Ij'mphatic  vessels  and  with  their  nodes  from  the  jugular  lymphatic 
plexus  and  terminate  below  in  the  jugular  lymphatic  trunk. 

A  little  study  of  the  diseases  of  the  eye,  ear,  nose  and  throat  in  con- 
junction with  lymphatic  circulation  and  its  nodes,  will  aid  materially  in 
the  understanding  of  right  diagnosis  and  treatment. 

In  children  having  furunculosis  of  the  external  auditory  canal  or 
some  infection  in  that  region,  enlarged  nodes  may  be  noticed  just  over 
the  insertion  of  the  sternocleidomastoid  muscle.  Infection  in  the  naso- 
pharynx or  phar\aix  and  the  sphenoidal  sinus  may  cause  enlargement  of 
the  occipital  nodes,  the  superior  deep  cervical  nodes  just  back  of  the 
sternocleidomastoid  muscle.  Also,  the  inferior  deep  cervical  nodes 
may  be  enlarged  from  disease,  infection  and  poisoning  from  any  region 
in  the  head. 

Infection  in  the  parotid  gland  or  its  immediate  vicinity,  the  eye  lids 
or  the  external  ear  will  enlarge  the  parotid  nodes,  apparently  enlarging 
the  parotid  gland.  Infection  in  the  orbit,  in  the  sinuses  in  the  region  of 
the  soft  palate  and  pharynx  may  show  an  apparent  thickening  in  the 
region  of  the  buccinator  muscle  on  account  of  the  enlargement  of  the 
deep  facial  nodes. 

The  most  common  place  to  find  enlarged  lymphatic  nodes  is  in  the 
submaxillary  region.  The  reason  for  this  is  that  efferent  vessels  from 
practically  all  the  nodes  above  enter  the  submaxillary  nodes.  Any 
infections  in  the  anterior  nose  or  the  teeth  may  cause  an  enlargement  of 
the  submaxillary  nodes.  It  is  quite  common  to  find  the  superficial 
cervical  nodes  enlarged  which  lie  upon  the  sternocleidomastoid  and 
along  its  posterior  border  and  at  the  inferior  border  of  the  parotid  gland. 
These  nodes  receive  efferent  vessels  from  the  nodes  above. 

Infection  in  the  pharynx,  tonsils,  nasopharynx,  middle  ear.  Eus- 
tachian tube  or  the  internal  ear  may  carry  infection  into  the  superior 
deep  cervical  nodes  in  the  carotid  fossa  along  the  internal  jugular  vein. 
In  tonsillar  infection,  one  or  two  of  the  large  superior  deep  cervical 
nodes  are  almost  constantly  enlarged.  It  is  one  of  the  diagnostic  signs 
of  infection  or  absorption  of  toxic  material  from  the  tonsillar  area. 

Our  treatment  should  be  directed  to  the  opening  up  not  only  of 
blood  circulation  but  of  freeing  the  lymph  circulation  in  the  treatment 
of  diseases  of  the  eye,  ear,  nose  and  throat.  The  lymph  drainage,  of 
course,  is  always  in  this  region  from  above  downward.  Any  sources  of 
focal  infection  should,  of  course,  be  cleared  up  in  order  to  relieve  the, 
lymph  from  the  burden  of  counteracting,  eliminating  and  constantly 
absorbing  toxins. 


GLENN  S.  MOORE,  D.  O. 
Chicago,  III. 


CHAPTER  ELEVEN 

PART  TWO— LYMPHATICS  OF  THE  EYE  AND  EAR 

Glenn  S.  Moore,  D.  O.,  Chicago 

Lymph  drainage  is  an  important  feature  in  the  balance  of  the  body 
mechanism,  and  the  factors  whereby  this  physiological  equilibrium  is 
maintained  are  of  utmost  importance  to  the  patient  and  to  the  pro- 
fession. 

In  the  following  brief  summary  we  shall  endeavor  to  give  a  concise 
and  accurate  statement  of  fact  concerning  the  lymphatic  system,  with 
suggestions  as  to  the  most  effective  points  of  approach  for  the  opening 
of  the  drainage  from  the  eye  and  from  the  ear. 

The  Eye 

The  lymphatics  of  the  eye  are  numerous  and  extensive.  They  con- 
sist largely  of  lymph  spaces  which  communicate  directly  or  indirectly 
with  one  another.  In  addition  to  the  lymph  system  of  the  lid,  there 
are  virtually  two  lymph  systems  which  are  termed  the  anterior  and 
posterior  group  systems.  In  the  anterior  group  are  the  lymph  spaces  of 
the  cornea,  of  the  iris  and  of  the  aqueous  humor.  The  aqueous  humor 
passes  from  the  posterior  chamber  to  the  anterior  chamber,  escaping  by 
way  of  the  spaces  of  Fontana  and  the  canal  of  Schlemm,  eventually 
draining  through  the  spheno-maxillary  fissure  to  the  internal  maxillary 
and  deep  parotid  lymph  glands.  The  posterior  group  of  spaces  contains 
the  Hyaloid  canal  which  extends  from  the  optic  disc  to  the  posterior  pole 
of  the  lens,  draining  the  inter-vaginal  space  of  the  optic  nerve.  In  ad- 
dition there  is  in  this  group  the  perichoroid  lymph  space  whose  lymph 
empties  into  the  Tenon  space  "by  perforation  in  the  sclera  around  the 
venae  verticose. "  Tenon's  space  which  empties  into  the  supra-vaginal 
space,  and  the  inter-vaginal  space  complete  the  list,  the  last  mentioned 
of  which  opens  into  the  subdural  and  subarachnoid  spaces  of  the  brain. 

According  to  Deaver,  any  obstruction  in  the  anterior  lymph  chan- 
nels will  cause  an  increase  in  intra-ocular  pressure.  For  example,  such 
conditions  as  annular  posterior  synechia,  involving  the  entire  pupillary- 
margin  of  the  iris  to  the  extent  of  causing  it  to  adhere  to  the  anterior 
surface  of  the  capsule  of  the  lens  will  prevent  the  lymph  of  the  posterior 
chamber  from  entering  the  anterior  chamber  through  the  pupil.  This 
would  result  in  causing  the  iris  to  project  against  the  cornea,  closing  off 
the  drainage  through  the  spaces  of  Fontana  and  the  canal  of  Schlemm. 
Such  a  serious  condition  gives  rise  to  a  symptom  complex  known  as 

—183— 


184  Lymphatics 

glaucoma.  In  addition  to  this,  glaucoma  may  result  from  a  hyper- 
secretion of  lymph  in  the  eyeball.  I  am  of  the  opinion  that  many  cases 
of  glaucoma  which  we  are  treating  today  with  good  results  are  of  this 
type. 

In  summarizing,  therefore,  we  have  a  triple  lymphatic  drainage 
from  the  eye  by  way  of  first,  the  eyelid,  through  the  buccal  and  sub- 
maxillary lymph  glands  of  the  head  to  the  superficial  lymph  glands  of 
the  neck.  Secondly,  this  drainage  is  by  way  of  the  anterior  lymph  chan- 
nels of  the  eyeball  (canal  of  Schlemm  and  spaces  of  Fontana  and  anterior 
posterior  chambers)  all  draining  to  the  internal  maxillary  lymph  glands. 
The  third  avenue  of  drainage  is  by  way  of  the  posterior  channels  of  the 
eyeball  (Hyaloid  canal,  supra-  and  infra-vaginal  lymph  spaces  and  peri- 
choroid lymph  space)  all  draining  to  the  subdural  and  subarachnoid 
spaces  of  the  brain. 

The  Ear 

The  ear  proper  is  divided  into  three  parts,  the  External  ear.  Middle 
ear,  and  Inner  ear,  each  having  a  distinct  lymphatic  drainage.  The 
lymphatics  of  the  external  ear  drain  into  the  parotid  and  the  superficial 
cervical  lymph  glands.  Infections  of  the  external  ear  manifest  themselves 
by  tenderness  in  the  parotid  lymph  glands,  maxillary  lymph  gland  or 
superficial  lymph  glands  of  the  neck.  The  Middle  Ear  is  drained  by  the 
lymphatics  which  pass  out  through  the  external  auditory  canal  to  join 
the  superficial  lymph  glands  of  the  neck.  Lymph  vessels  also  pass 
down  the  lymphatic  system  of  the  neck.  The  lymph  of  the  Inner  Ear 
communicates  with  the  subdural  and  subarachnoid  spaces  of  the  brain. 

Summary 

In  conclusion,  it  is  to  be  noted  that  the  eye  and  the  ear  have  a  some- 
what correlative  system  of  lymph  drainage.  This  drainage  includes 
the  subdural  and  subarachnoid  spaces  of  the  brain  which  are  partial 
terminals  of  the  drainage  of  the  more  intricate  structures  of  the  organs. 
So  far  as  the  superficial  and  deep  drainage  of  the  neck  is  concerned,  the 
facilitation  of  this  drainage  is  brought  about  by  the  deep  relaxing  of 
the  region  of  the  clavicle  and  first  rib.  By  so  doing  the  drainage  is 
"freed,"  as  we  say,  that  is,  there  is  brought  about  an  actual  minute  in- 
crease in  the  intervascular  spaces  allowing  for  the  greater  flow  of  blood 
and  lymphatic  fluid  because  of  the  mechanical  as  well  as  chemical  changes 
which  become  possible. 

The  muscular  relaxation  which  is  involved  in  the  process  helps  to 
lift  the  mechanical  pressure  which  by  tightening  of  the  fibres  has  brought 


Eye  and  Ear  185 

about  contracture  of  the  whole  region.  In  addition  to  this  there  is  ac- 
compHshed  a  metaboHc  process  of  repair  of  the  cells  which,  because  of 
interference  with  drainage  and  nutrition,  have  become  over-laden  with 
toxic  products  such  as  CO™  and  other  substances.  By  virtue  of  the 
"freeing  up"  process  this  intracellular  drainage  is  accomplished  and  the 
intercellular  accumulation  of  edematous  material  is  allowed  to  flow  more 
freely  downward  to  the  subclavian  vein. 

Therefore,  the  clavicular  work  is  indical^ed  in  general  introductory 
work  for  all  cases  involving  the  lymphatics  of  Eye  and  Ear.  It  should 
not  be  considered  as  purely  introductory,  for  it  will  be  well  in  all  cases  of 
inflammation  of  either  organ  to  continue  the  clavicular  treatment  as 
long  as  indicated  for  drainage. 

The  special  treatment  as  originated  by  Dr.  Edwards  for  local  free- 
ing of  t^e  lymph  is  of  great  value  after  the  general  freeing  of  the  deep 
and  su^erflcial  lymph  drainage  of  the  neck.  Treatment  at  the  first, 
second  ^nd  third  lumbar  helps  to  open  the  cerebrospinal  lymph  drainage 
thus  clearing  the  way  for  the  special  local  treatment  of  the  inner  ear. 


J.  DEASON,  M.  S.,  D.  O. 
Chicago,  III. 


CHAPTER  TWELVE 

LYMPHATIC  DRAINAGE  OF  THE  HEAD  AND  NECK 

J.  Deason,  M.  S.,  D.  O. 
Physiologic  Properties  of  Lympli 

To  understand  fully  the  function  of  an  organ  requires  not  only  that 
we  understand  its  histologic  and  gross  structure  and  the  relation  of  these 
to  the  work  it  has  to  do,  but  we  must  also  understand  the  structural  and 
functional  relations  of  this  organ  with  other  similar  organs. 

Anatomically,  lymph  vessels  are  similar  to  veins  of  the  blood-vas- 
cular system  in  that  they  are  thin-walled  and  serve  as  drainage  channels, 
but  they  are  unlike  veins  in  that  they  drain  intracellular  spaces  and 
serous  sacs.  They  are  also  unlike  veins  in  their  abundant  interlacing 
anastomoses  and  the  interruption  of  their  continuity  by  lymph  glands 
or  nodes.  By  virtue  of  this  construction  lymph  vessels  serve  as  drain- 
age channels  from  many  parts  not  drained  by  the  venous  system. 

Lymph  vessels,  therefore,  serve  a  transitional  function  between  in- 
tracellular spaces  and  veins  as  they  serve  to  collect  the  fluid  from  the 
intracellular  spaces  and  return  it  to  the  veins.  Lymph  vessels  may  be 
thought  of  as  the  primary  or  first  structures  of  circulation.  Lymph 
vessels  bear  a  similar  relation  to  the  veins  that  the  veins  bear  to  arteries, 
and  all  of  these,  in  order,  efferently,  the  arteries,  veins,  and  intracellular 
spaces,  and  afferently,  the  intracellular  spaces,  lymph  vessels  and  veins, 
constitute  the  essential  circulatory  mechanism  and  each  is  important  in 
carrj'ing  nutrition  to  and  waste  products  from  the  cell,  which  is  funda- 
mentally^ the  unit  of  function. 

Physiologically,  lymph  performs  an  important  protective  function 
by  virtue  of  its  phagocytic  cells  and  antibody  content;  a  nutritional 
function  by  virtue  of  its  supply  of  nutrient  material  and  drainage  of 
cell  waste  from  tissue  spaces;  and  a  tissue  fluid  balance  function  because 
of  its  osmotic  properties.  The  lymphatic  system,  structurally  and  func- 
tionally, bears  a  relation  to  the  veins  similar  to  that  which  the  veins 
bear  to  the  arteries. 

General  Anatomy 

Lymphatic  vessels  of  the  head  and  neck  are  distinguished  as  super- 
ficial and  deep.  The  former  drain  the  subcutaneous  tissues  and  super- 
ficial  muscles  of  the  face  and  scalp  and  terminate  in  the  superficial  glands 
of  the  neck.  The  deep  vessels  are  those  which  drain  the  deep  muscles, 
the  nasopharyngeal  structures,  sinuses  and  glands,  the  oropharynx  and 

—187— 


188  Lymphatics 

contents,  the  orbit  and  contents,  larynx,  esophagus  and  trachea.  These 
empty  into  various  groups  of  deep  glands  which  form  a  belt  about  the 
neck. 

Intracranial  lymph  vessels  from  the  brain  and  meninges  follow  the 
courses  of  the  arteries  and  veins  and  empty  into  the  deep  cervical  glands. 

Groups  of  Deep  Cervical  Glands 

Parotid  Lymph  Glands. — These  glands  are  superficial  and  deep, 
the  superficial  being  located  just  beneath  the  fascia,  and  the  deep  im- 
bedded within  the  parotid  gland.  The  superficial  glands  receive  af- 
ferent vessels  from  all  anterior  superficial  parts  of  the  scalp  and  face  in- 
cluding the  external  ear.  Swelling  of  these  glands  may  result  from  in- 
fection  of  any  of  the  parts  drained.  Efferents  of  these  glands  drain  into 
either  superficial  or  deep  cervical  glands,  which  explains  why  a  deep 
cervical  swelling  may  result  from  superficial  infection. 

The  deep  parotid  lymph  glands  receive  afferent  vessels  from  the 
external  meatus,  tympanum,  soft  palate,  and  posterior  nares.  Efferent 
vessels  drain  into  the  upper  deep  cervical  glands. 

Application. — The  swelling  and  tenderness  of  these  glands,  to- 
gether with  ear  pain,  is  quite  diagnostic  of  infection  of  the  middle  ear. 
Infections  of  the  external  ear  are  not  so  likely  to  cause  lymphatic  swelling 
because  there  is  usually  free  drainage. 

Infections  of  the  nasopharynx  and  posterior  nares  cause  glandular 
enlargement  and  these  structures  are  nearly  always  involved  in  suppu- 
rative otitis  media. 

"The  deep  part  of  the  parotid  gland  is  lodged  in  a  definite  space 
behind  the  ramus  of  the  lower  jaw.  This  space  is  increased  in  size  when 
the  head  is  extended,  and  when  the  inferior  maxilla  is  moved  forward, 
as  in  protruding  the  chin. "  (Treves).  This  explains  why  pain  is  caused 
by  all  movements  which  tend  to  decrease  the  space  of  this  gland,  such 
as  chewing,  swallowing,  etc. 

The  superficial  part  of  the  gland  lies  over  the  masseter  muscle  and 
the  whole  gland  is  invested  in  a  fascial  sac  derived  from  cervical  fascia. 
The  opening  of  the  upper  part  of  this  sac  is  exposed  to  infections  from 
postpharyngeal  abscess,  which  explains  the  common  occurrence  of 
pharj^ngitis  and  parotiditis. 

In  otitis  media,  pharyngitis,  postnasal,  nasopharyngeal,  and  tonsil 
infections,  in  addition  to  other  treatment,  it  is  essential  that  lymphatic 
drainage  of  the  parotid  lymph  glands  be  established  and  maintained. 
Deep  drainage  treatment  may  be  done  by  direct  relaxation  behind  and 
under  the  angles  of  the  jaws  with  the  head  well  extended.     By  forcing  the 


Drainage  of  the  Head  and  Neck 


189 


Plate  XLVIII.  Ljiaphatics  of  the  Pharyngeal  Region. — (1)  Nodes  back 
of  pharynx.  (2  &  3)  Deep  cervical  nodes.  (4)  Retro-pharyngeal  node. 
(5)  Tracheal  nodes.  (6)  Lymph  vessels  entering  thoracic  duct.  (7) 
Right  lymphatic  duct.  (8)  Thoracic  duct.  (9)  Mastoid  nodes.  (10) 
Carotid  artery. 


190  Lymphatics 

head  and  jaw  backward  thus  compressing  these  glands  and  again  ex- 
tending  and  repeating  the  direct  deep  drainage  treatment,  the  glands  and 
vessel?  may  be  "pumped"  and  made  to  increase  their  function  of  drain- 
age.  Except  in  acute  inflammatory  conditions,  direct  stretching  of  the 
soft  palate  and  dilatation  of  the  posterior  nares  by  means  of  the  fingers 
are  effective;  also  exercises  for  draining  the  cervical  lymph  glands  and 
exercising  the  muscles  of  the  neck  are  effective. 

It  is  important  to  remember  that  the  fascial  sac  covering  the  parotid 
gland  is  closed  except  at  its  upper  part,  and  that  swelling  of  the  gland 
and  coverings  retard  drainage.  Heat  applied  intermittently,  which  may 
be  accomplished  best  by  means  of  an  electric  pad  or  lamp  with  reflector, 
produces  capillary  dilatation  and  contraction  and  materially  assists  in  in- 
creasing drainage  from  the  gland.  Bier's  hyperemic  treatment  may  be 
done  by  placing  a  tight  bandage  immediately  beneath  the  glands  until 
the  face  is  flushed  and  the  vessels  are  engorged.  The  bandage  is  then 
removed,  the  head  extended,  and  the  deep  manipulative  treatment  be- 
hind and  under  the  angles  of  the  jaws  causes  an  effective  and  quick 
drainage.  This  flushing  treatment  may  be  repeated  several  times  daily 
with  good  effect. 

Postpharyngeal  Lymph  Glands. — These  glands  are  located  pos- 
terior to  the  walls  of  the  pharynx,  and  anterior  to  the  first  and  second 
cervical  vertebrae.  They  receive  afferent  vessels,  from  the  nasal  cav- 
ities and  the  nasal  accessory  sinuses,  from  the  nasopharynx,  pharyngeal 
tonsil.  Eustachian  tube,  the  middle  ear,  and  other  adjacent  deep  struc- 
tures. Since  these  structures  are  so  commonly  the  source  of  infection, 
the  postpharj'^ngeal  glands  are  oft«n  involved  and  retro-pharyngeal 
abscess,  with  its  various  complications,  is  not  uncommon.  Efferent 
vessels  of  these  glands  drain  into  the  deep  cervical  lymph  glands,  there- 
fore involvement  of  the  cervical  glands  frequently  results  from  infec- 
tion of  the  various  structures  named  above. 

Application. — The  abundant  anastomoses  of  the  lymphatic  vessels 
and  the  fact  that  lymph  flows  rather  freely  in  any  direction,  explains 
the  common  extension  of  infections  from  a  glandular  center.  Extension 
of  infection  from  the  postpharyngeal  glands,  involving  the  various 
structures  of  the  pharynx,  larynx  and  oral  cavity,  is  common.  This 
explains  why  tonsillitis,  pharyngitis,  and  even  infections  of  the  gums, 
may  result  from  sinuitis  or  an  infected  nasopharynx,  which  is  common, 
and  this  explains  why  tonsillitis  may  often  be  relieved  by  removal  of 
the  adenoids  and  the  proper  treatment  of  the  nasopharynx,  sinuses  and 
nares.  Inflammatory  (catarrhal)  diseases  of  the  Eustachian  tube  and 
middle  ear  frequently  result  from  infections  of  the  nasopharynx,  adenoid 


Drainage  of  the  Head  and  Neck  191 

growths  or  adhesions  resulting  from  their  incomplete  atrophy,  intra- 
nasal or  sinus  infections,  and  the  source  of  this  inflammation  must  be 
successfully  treated  before  the  ear  affection  can  be  controlled.  Exten- 
sion of  inflammation  along  the  walls  of  the  Eustachian  tubes  from  phar- 
yngeal infections  is  the  most  common  cause  of  catarrhal  deafness.  Ton- 
sillar infection  is  the  primary  cause  of  pharyngeal  infection  in  some  cases, 
but  from  the  evidence  given  above  and  from  clinical  observation,  I  be- 
lieve that  sinus,  intranasal  and  nasopharyngeal  infections  are  more  often 
the  cause  of  ear  trouble  than  is  tonsillitis. 

Any  treatment  which  does  not  actually  remove  the  cause  of  in- 
fection or  physical  irritation  of  the  pharynx  cannot  be  considered  an 
efficient  treatment  for  catarrhal  deafness.  Sinus  infections,  intranasal 
infections  and  definite  obstructions  to  normal  intranasal  drainage  must 
be  properly  treated.  The  same  is  true  of  intrapharyngeal  obstructions 
and  sources  of  infection.  To  crush  adenoids  or  pharyngeal  adhesions 
without  actually  removing  every  part  that  may  interfere  with  postnasal 
drainage  cannot  produce  the  best  results,  because  the  source  of  the 
trouble  has  not  been  removed,  and  here  is  wherein  the  so-caUed  "finger 
surgery"  technic  alone,  fails  to  accomplish  the  best  results.  The  direct 
treatment  of  the  Eustachian  tube  and  surrounding  structures  will  re- 
sult in  partial  and  temporary  results,  only,  unless  the  causes  of  inflamma- 
tion are  removed. 

Persistent  colds  in  the  head,  pharyngitis,  laryngitis,  voice  impair- 
ment, etc.,  likewise  are  often  caused  and  maintained  by  extension  of  in- 
fection from  the  postpharyngeal  lymphatic  glands,  and  the  same  princi- 
ples of  treatment  apply. 

In  acute  infections  of  the  postpharyngeal  glands,  the  same  treat- 
ment as  given  above  under  ''Parotid  Lymph  Glands,"  applies.  How- 
ever, in  all  acute  infections  it  is  a  good  rule  to  do  no  or  very  little  direct 
treatment  of  the  parts  involved.  There  are  exceptions  to  this  rule, 
but,  in  general,  it  is  a  safe  plan  to  follow  because  radical  treatment  may 
often  result  in  an  extension  of  the  infection  rather  than  reUeve  it. 

Anterior  Pharyngeal  Lymph  Glands 

According  to  Treves,  "Accessory  glands,  belonging  to  the  thyroid 
body,  are  frequently  found  in  the  vicinity  of  the  hyoid  bone.  They 
are  also  found  in  the  basal  part  of  the  tongue,  near  the  foramen  caecum. " 

In  many  cases  of  acute  disease  the  swelling  of  these  glands  like  the 
postpharyngeal  glands  cause  much  soreness  and  discomfort.  In  ton- 
sillitis, pharyngitis,  etc.,  there  is  usually  some  affection  of  these  glands, 
but,  as  stated  above,  direct  treatment  is  not  indicated  during  the  acute 


192  Lymphatics 

stage.  Deep  relaxation  under  the  angles  of  the  jaws  externally  will 
facilitate  drainage.  After  the  acute  stage  has  passed,  direct  treatment 
may  be  done  as  follows:  The  two  cornui  of  the  hyoid  are  grasped  be- 
tween the  thumb  and  second  fingers  of  the  left  hand,  palm  upward,  while 
the  first  and  second  fingers  of  the  right  hand  are  passed,  palm  downward, 
over  the  base  of  the  tongue  thus  holding  the  hyoid  firmly  between  these 
four  fingers.  The  hyoid  may  now  be  lifted  upward  and  thus  by  virtue 
of  its  attachment  to  the  thyroid  cartilage,  the  entire  larynx  may  be  lifted. 
The  hyoid  is  held  in  this  position  for  a  few  seconds,  then  pulled  firmly 
forward  and  then  downward  and  by  these  movements  the  pharyngeal 
constrictors  may  be  relaxed  and  lymphatic  and  venous  drainage  ac- 
complished. 

In  chronic  pharyngitis  and  laryngitis  this  treatment  will  be  found 
quite  effective.  To  accomplish  the  desired  results  the  purpose  and 
technic  of  the  treatment  must  be  considered  and  the  treatment  must  not 
be  painful  to  the  patient  or  the  proper  relaxation  will  not  be  accom- 
plished. 

Tonsils  and  Lymph  Drainage 

The  group  of  lymphoid  tissue  commonly  known  as  Waldeyer's 
tonsillar  ring,  consisting  of  faucial,  lingual  and  pharyngeal  tonsils,  is 
frequently  affected  by  infections  carried  through  the  lymph  channels. 
The  pharyngeal  tonsils  or  adenoids  are  often  involved  secondary  to 
sinus  infections  and  the  faucial  tonsils  are  also  frequently  infected  as  a 
result  of  either  adenoid,  posterior  nasal  or  sinus  infections.  In  all  cases 
of  faucial  tonsillitis  it  is  essential  to  determine  whether  there  is  some  in- 
fection above.  Many  cases  of  faucial  tonsillitis  will  be  entirely  relieved 
by  the  proper  treatment  of  the  nasal  accessory  sinuses,  posterior  nasal 
chambers  and  the  nasopharynx. 

There  is  no  positive  evidence  that  the  faucial  tonsils  have  a  func- 
tion different  from  other  lymphoid  tissue,  and  since  this  tissue  is  usually 
excessive  there  is  no  reason  why  the  tonsils  should  not  be  removed  sur- 
gically so  far  as  any  loss  of  function  is  concerned  when  they  are  patho- 
logically involved  beyond  restoration  to  normal,  but  because  of  reasons 
given  above  it  is  more  logical  to  sacrifice  the  adenoid  tissue  first.  Many 
cases  of  faucial  tonsil  involvement  will  be  promptly  relieved  by  adenoid- 
ectomy  and  the  proper  treatment  of  the  entire  nasopharynx  sinuses. 

Tubercular  Tonsillitis 

From  the  study  of  my  cases  I  am  convinced  that  tubercular  infec- 
tions of  the  tonsils  is  frequently  secondary  to  tubercular  sinuitis.  To 
diagnose  tubercular  tonsillitis  it  is  neceessary  to  first  thoroughly  clean 


Drainage  of  the  Head  and  Neck 


193 


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1 

Plate  XLIX.  Lymph  Drainage  of  Throat. — (])  Parotid  gland  and  nodes. 
(2)  Three-fold  drainage  by  lingual  Ijiiiphatics.  (3)  Nodes  in  relation 
to  submaxillar^  gland.  (4)  Lingual  lymph  vessels  in  relation  to  the  sub- 
lingual gland,  (o)  Carotid  artery.  (6)  Internal  jugular  vein.  (7) 
Nodes  collecting  Ijinnh  from  teeth,  gums  and  tongue.  (8)  Lymphatic 
vessels  collecting  lymph  from  the  gums. 


194        ,  Lymphatics 

the  entire  pharynx  by  irrigation,  swabbing  and  gargling  and  then  ob- 
tain pus  from  the  crypts  of  the  tonsils  by  cupping  or  by  means  of  probing 
deeply  into  the  crypts  and  making  stains  of  the  pus  thus  obtained. 

The  tonsils  may  be  the  primary  source  of  tubercular  infection  but 
a  tubercular  infection  of  the  tonsils  is  rarely  confined  to  that  locality 
long.  There  is  usually  evidence  of  an  extension  to  the  sinuses,  lungs  or 
cervical  lymph  glands  and  when  there  is  an  active  involvement  of  any  of 
these  other  structures  it  is  essential  to  arrest  the  active  infection  in  the 
lungs,  sinuses  or  lymph  glands  before  advising  tonsillectomy. 


J.  D.  EDWARDS,  D.  O.,  M.  D. 
St.  Loris,  Mo. 


CHAPTER  THIRTEEN 

FINGER  SURGERY  IN  THE  TREATMENT  OF  THE 
LYMPHATICS  OF  THE  EYE,  EAR,  NOSE  AND 

THROAT 

James  D.  Edwards,  D.  O.,  M.  D.,  St.  Louis 

In  the  study  of  the  lymph  drainage  of  the  eye,  ear,  nose  and  throat 
we  are  opening  one  of  the  most  fascinating  chapters  of  Osteopathy,  a 
subject  of  which  our  knowledge  is  still  so  limited  that  it  is  as  but  a  minute 
scratch  upon  the  veneer.  The  first  productive  stimulus  to  this  subject 
was  created  by  the  theory  of  fermentation  of  the  lymph  in  the  lymphatics 
as  propounded  by  the  "Old  Doctor"  (Dr.  A.  T.  Still)  and  subsequently 
developed  by  Dr.  F.  P.  Millard.  In  the  early  days  of  Osteopathy  the 
"Old  Doctor"  expressed  the  opinion  that  each  lymphatic  created  a 
specific  substance,  which  is  discharged  into  the  blood,  and  that  these 
substances  are  necessary  to  the  integrity  of  the  organism.  The  frequent 
references  to  the  humors  and  refluxes  of  earlier  writers  indicate  that  they 
had  a  preconceived  notion  of  the  lymphatics,  the  nature  and  source  of 
which  were  at  that  time  bound  up  in  apparently  unfathomable  mys- 
tery. 

It  is  to  the  physiological  chemist  that  we  must  look  for  the  develop- 
ment of  our  knowledge  of  this  most  intricate  subject.  The  gross  and 
histological  anatomy  as  well  as  the  patholog>'  of  the  structural  elements 
of  the  lymphatic  system  have  been  quite  thoroughly  investigated,  but 
there  is  still  a  vast  amount  of  work  to  be  done  in  isolating  and  determin- 
ing the  remarkable  properties  of  the  active  principles  of  the  lymph  drain- 
age. The  clinical  progress  of  the  subject  has  within  past  years,  and  par- 
ticularly of  late,  made  rapid  strides  forward,  and  an  ever-increasing  in- 
terest and  enthusiasm  stimulated  in  those  who  have  become  initiated 
in  this  most  fascinating  phase  of  clinical  study. 

The  subject  matter  of  this  chapter  is,  in  brief,  a  repetition  of  what 
I  have  peviously  expressed  as  clinical  observations,  which  have  been  so 
forcibly  verified  by  personal  clinical  experience  as  to  create  an  interest 
in  a  subject  which  solves  many  of  the  innumerable  problems  incident 
to  the  practice  of  Osteopathy.  It  is  my  purpose  to  limit  my  remarks 
to  the  important  relationship  existing  between  the  lymphatics  of  the 
eye,  ear,  nose  and  throat,  and  the  diseases  treated  by  the  osteopathic 
ophthalmologist  and  otolaryngologist.  An  understanding  of  this  phase 
of  physiology,  in  its  normal  and  abnormal  reactions,  is  of  paramount  ira- 

—197— 


198 


Lymphatics 


Plate  L.  Finger  surgery  of  the  upper  lid  in  the  treatment  of  external  dis- 
eases of  the  eye.  The  little  finger  of  the  right  hand  is  stretching  and 
relaxing  the  upper  lid,  while  the  thumb  and  forefinger  of  the  opposite 
hand  are  rolling  the  tarsus  over  the  inserted  finger. 


Finger  Surgery  199 

portance,  and  serves  an  incalculable  aid  in  the  analysis  and  treatment  of 
the  upper  orifices. 

Disgruntled  osteopaths,  feeling  the  ground  slipping  from  under  their 
feet,  have  shouted  against  the  various  methods  which  in  recent  years 
have  forged  to  the  front.  They  have  intimidated  the  credulous  by  at- 
tributing to  the  men  interested  in  the  specialties  statements  which  were 
far  beyond  any  assertions  that  have  been  made,  and  in  the  same  un- 
reasonable manner  they  continued  destroying  the  house  of  their  own 
creation.  Strong-arm  osteopaths,  clinging  to  set  classifications  and 
trustworthy  manipulations,  have  protested  against  the  invasion  of  the 
osteopathic  specialist.  Frequently,  fearful  of  revealing  their  own  con- 
flicts and  shortcomings,  they  assailed  the  process  as  injurious  and  costly. 
They  shook  their  heads  solemnly  and  told  how  pernicious  it  was  for  the 
recent  graduate  to  enter  the  specialties. 

They  stated  that  dilatation  of  the  pharyngeal  orifice  of  the  Eusta- 
chian tube  was  not  feasible,  and  they  sometimes  denied  the  efficacy 
of  a  curettage  of  the  fossa  of  Rosenmuller.  How  could  there  be  such  a 
thing  as  a  palpable  Eustachian  orifice  when  it  was  all  one  could  do  to 
understand  the  workings  of  the  auditory  apparatus? 

It  is  easy  to  recall  the  time  when  anatomists,  in  their  search  for 
truth,  were  persecuted  and  regarded  as  enemies  to  society.  While  our 
present  status  in  regard  to  finger  surgery  is  nothing  about  which  to  boast, 
nevertheless  it  is  a  relief  to  know  that  this  sort  of  cowardice  has  not 
manifested  itself  to  a  sufficient  degree  to  halt  the  chariot  of  progress. 

Lymph  Drainage  of  the  Eyelids 

There  are  two  networks  of  lymphatics  which  follow  the  correspond- 
ing veins.  The  networks  are  connected  by  vessels  which  pierce  the 
tarsus.  The  lymphatics  empty  into  the  submaxillary,  preauricular, 
and  parotid  lymphatic  glands.  The  preauricular  gland  is  often  enlarged 
in  diseases  of  the  lids. 

In  blepharitis  marginalis,  chronic  catarrhal  conjunctivitis,  trachoma, 
dacryocystitis,  chalazion,  hordeolum,  and  other  infections  it  is  essential 
that  lymphatic  drainage  of  the  tarsus  be  re-established.  Finger  surgery 
of  the  upper  lid,  in  addition  to  structural  adjustments,  has  worked  won- 
ders in  the  treatment  of  external  diseases  of  the  eye. 

To  treat  the  upper  lid,  the  nail  of  the  little  finger  should  be  trimmed 
below  the  cushion,  and  the  phalanges  thoroughly  cleansed  and  lubri- 
cated with  some  mild  antiseptic  fluid.  (Incidentally,  I  may  remark  that 
I  have  found  the  "Williams  antiseptic  fluid"  very  efficacious  in  this 
technic).     The  first  phalanx  of  the  little  finger  (palm  upward)  is  gently 


200 


Lymphatics 


Plate  LI.  Finger  surgery  of  the  ocular  lymphatics  (first  step).  The  fore- 
fingers of  both  hands  are  retracting  and  depressing  the  upper  and  lower 
lids  as  the  globe  is  gradually  lifted  out  of  its  cavity  and  upon  the  rim 
of  the  orbital  fossa. 


'     Finger  Surgery  201 

passed  beneath  the  upper  lid,  upward  and  backward,  to  the  supraorbita 
space.  The  thumb  and  forefinger  of  the  opposite  hand  support*!  the 
upper  hd,  feeding  it  over  the  Httle  finger  during  the  insertion.  The 
interference  and  purchase  power  of  the  inferior  palpebra  can  be  avoided 
by  depressing  the  lower  hd  with  the  index  finger  of  the  left  hand,  and  as 
this  is  done  the  httle  finger  of  the  right  hand  will  pass  into  space.  The 
thumb  and  forefinger  of  the  opposite  hand,  resting  upon  the  upper  lid,, 
act  as  a  fulcrum  and  guide,  and,  by  raising  the  hand  of  the  inserted  finger 
(the  phalanges  being  held  rigid),  the  traction  is  referred  to  the  inner  and 
outer  canthus,  and  the  tarsus  is  treated  by  rolling  the  upj)er  hd  over  the 
inserted  finger.     (Plate  50). 

A  few  drops  of  a  two-per  cent,  solution  of  holocain  or  ah-pin,  allowed 
to  remain  a  few  minutes,  will  verj^  readily  anesthetize  the  tissues,  and 
the  httle  finger  can  be  inserted  with  verv'  httle  discomfort  to  the  patient. 

An  instillation  of  a  fifty-per  cent,  solution  of  alkalol  (not  alcohol),  a 
few  drops  in  each  ej'e,  is  used  as  a  prophylactic  measure  following  each 
treatment.  The  alkalol  is  very  soothing,  and  will  not  discolor  the  con- 
junctiva hke  instillations  of  the  silver  salts  (argjTol). 

The  Ocular  Lymphatics 

Lymphatics  have  not  bsen  found  in  the  cornea.  In  the  conjunc- 
tiva, lymphatic  vessels  are  present.  Elsewhere  in  the  ocular  structures 
their  places  are  taken  bj'^  hnnph  spaces,  which  fonn  two  systems — an 
anterior  and  a  posterior. 

Ball  says  that  the  h-mph  from  the  anterior  segment  of  the  globe 
collects  in  the  anterior  and  posterior  chambers,  whence  it  passes  through 
the  hgamentum  pectinatum  into  the  canal  of  Schlemm.  From  this 
channel  it  passes  into  the  anterior  ciliarj'  veins. 

The  posterior  hiuph  spaces  are:  (1)  The  hj'aloid  canal;  (2)  the  peri- 
choroidal space,  situated  between  the  choroid  and  sclera,  and  communi- 
cating by  means  of  spaces  around  the  venae  vorticosae  with  (3)  the 
space  of  Tenon,  which  lies  between  the  sclera  and  Tenon's  capsule.  From 
these  points  h-mph  collects  and  passes  into  (4)  the  intervaginal  space 
found  between  the  sheaths  of  the  optic  nerve  and  (5)  the  supravaginal 
space  which  surrounds  the  sheath  of  the  same  nerve.  LvTnph  spaces 
surround  the  retinal  veins  and  capillaries  and  probabh'  the  arteries. 
Occlusion  of  the  anterior  lymph  space  is  one  of  the  phenomena  of  glau- 
coma and  nothing  is  known  concerning  occlusion  of  the  posterior  spaces. 
(B). 

In  the  treatment  of  glaucoma,  optic  ner\^e  atrophj^  choroiditis, 
cataracts,   and  other  nonsuppiu-ative  processes,  finger  surgerj'  of  the 


202 


Lymphatics 


Plate  LI  I.  Finger  surgery  of  the  ocular  lymphatics  (second  step).  The 
forefingers  of  both  hands  are  elevating  and  dislocating  the  eyeball,  there- 
by bringing  traction  upon  the  optic  nerve,  and  relaxing  the  musculature 
and  deep  tissues  of  the  orbital  cavity. 


FiNGEK  Surgery 


203 


Plate  LI II.  Finger  surgery  of  the  external  auditory  meatus.  The  fore- 
finger is  dilating  the  meatus  in  the  treatment  of  the  lymphatics  of  the 
aiu"icle  and  canal. 


204  Lymphatics 

globe  is  the  teehnic  par  excellence.  Frequently,  where  only  failure 
results  from  other  modes  of  therapy,  excellent  results  are  obtained  by 
this  new  osteopathic  treatment  of  the  ocular  lymph  spaces. 

In  the  treatment  of  the  ocular  lymphatics  the  writer  elevates  and 
dislocates  the  eyeball,  the  forefingers  of  both  hands  retracting  and  de- 
pressing the  upper  and  lower  lids  as  the  globe  is  gradually  lifted  out  of 
its  cavity  and  upon  the  rim  of  the  orbital  fossa.  The  eyeball  is  allowed 
to  remain  in  this  position  until  there  is  a  marked  injection  of  the  con- 
junctiva, indicating  a  change  in  the  vascular  supply.  The  orbit  is  easily 
replaced  by  releasing  the  lids,  applying  careful  and  steady  pressure  on 
the  sclera  and  a  slow  rocking  movement  to  the  globe.     (Plates  51,  52). 

These  manipulations  will  relax  the  musculature  and  deep  tissues  of 
the  orbital  cavity,  re-establish  the  lymph  spaces,  filtration  angle,  and 
normal  exits,  correct  the  physiologic  astigmatism,  which  is  due  to  lid 
pressure,  and  adjust  the  axial  ametropia,  which  is  due  to  malalignment 
of  the  extrinsic  muscles. 

A  few  drops  of  a  two  per  cent,  solution  of  holocain  or  alypin,  allowed 
to  remain  a  few  minutes,  will  very  readily  anesthetize  the  tissues,  and 
the  eyeball  can  be  elevated  and  dislocated  with  very  little  discomfort 
to  the  patient. 

I  have  administered  this  local  manipulation  of  the  eyeball  three 
times  a  week  for  six  months  or  more,  and  it  is  very  gratifying  to  see  the 
globe  change  from  a  passive  to  an  active  congestion  and  observe  the 
elimination  of  the  orbital  discomfort,  with  marked  improvement  in 
vision  and  often  with  the  complete  removal  of  the  glasses.  The  struc- 
tural adjustments  (osteopathic  lesions)  were,  of  course,  the  supportive 
measures  in  every  case. 

Lymphatics  of  the  Auricle  and  External  Auditory  Canai 

The  lymph  drainage  of  the  pinna  and  external  auditory  meatus  is 
very  closely  associated  with  the  lymphatics  of  the  mastoid  process  and 
parotid  gland.  Inflammatory  affections  of  the  external  meatus  will, 
as  a  rule,  invade  the  lymphatics  of  the  neighboring  tissues.  Politzer 
says  that  the  lymphatics  of  the  anterior  and  superior  walls  of  the  meatus, 
the  tragus,  and  the  surrounding  parts  empty  into  the  preauricular  glands 
(on  the  parotid) ;  that  those  of  the  lobule,  the  helix,  and  the  inferior  walls 
of  the  meatus  empty  into  the  infra-auricular  glands  (in  the  angle  of  the 
jaw) ;  that  those  of  the  antihelix  and  the  concha  empty  into  the  mastoid 
glands  (on  the  apex  of  the  mastoid  process);  and  that  those  of  the  pos- 
terior wall  of  the  meatus,  together  with  those  of  the  Eustachian  tube, 
empty  into  the  deep  cervical  and  retropharyngeal  glands.     The  tym- 


Finger  Surgery 


205 


Plate  LIV.  Millard's  bimanual  technic.  The  forefinger  of  the  right  hand 
is  dilating  the  right  external  auditory  canal,  while  the  forefinger  of  the 
left  hand  is  dilating  the  pharyngeal  orifice  of  the  right  Eustachian  tube 
(same  side),  in  the  treatment  of  catarrhal  deafness.  The  lymphatics 
at  both  ends  are  treated  at  the  same  time,  and  the  peripheral  inhibition 
stimulates  the  center. 


206 


Lymphatics 


Plate  LV.  Lymphatics  in  the  walls  of  the  pharynx  with  the  view  looking 
fonvard  to  the  posterior  nares  from  the  cervical  vertebrae  position.  The 
lymphatics  have  been  separated  from  the  membranes.  The  forefinger 
is  dilating  the  right  Eustachian  orifice.  This  cobweb  picture  is  very 
unique,  and  is  shown  for  the  first  time  in  any  text. 


Finger  Surgery  207 

panum  is  drained  by  the  lymphatics,  which  pass  out  through  the  ex- 
ternal auditory  meatus  to  join  the  superficial  glands  of  the  neck.  The 
lymph  drainage  of  the  labyrinth  is  closely  associated  with  the  subdural 
and  subarachnoid  spaces  of  the  brain. 

Finger  Surgery  of  the  Auditory  Lymphatics 

In  addition  to  structural  adjustments  (mandibular,  clavicular, 
cervical,  and  upper-dorsal),  digital  dilatation  of  the  external  auditory 
meatus  is  an  adjunct  par  excellence  in  the  treatment  of  diseases  of  the 
external  auditory  canal,  drumhead,  and  tympanum.  Otitis  externa 
circumscripta  and  diffusa,  tinnitus  aurium,  myringitis,  and  catarrhal 
deafness  have  responded  to  this  local  manipulation. 

Before  attempting  a  digital  dilatation,  the  canal  should  be  carefully 
examined  for  foreign  bodies,  be  freed  from  wax,  and  dry  swabbed.  The 
index  finger  should  be  thoroughly  cleansed,  with  nail  trimmed  below 
the  cushion,  and  not  lubricated. 

To  enter  the  external  auditory  meatus,  the  operator  stands  at  the 
head  of  the  table,  with  the  patient  in  a  recumbent  position.  The  index 
finger  (palm  upward)  is  slowly  and  carefully  inserted,  and  directed  up- 
ward and  backward,  with  gradual  rotation,  from  the  operator  toward 
patient's  shoulder.  During  the  rotation,  which  is  the  "knack"  of  the 
technic,  the  operator  should  not  use  his  wrist,  but  slowly  lean  forward  as 
the  finger  passes  upward  and  backward  into  the  canal.  The  finger 
should  not  be  instantly  withdrawn,  but  allowed  to  remain  a  minute  or 
two  in  location,  and  the  technic  should  be  repeated  several  times  at  each 
treatment.     (Plate  53). 

To  properly  dilate  the  external  auditory  meatus  requires,  as  a  rule, 
from  six  to  twelve  treatments,  but  this  technic  should  not,  however,  be 
administered  more  than  three  times  a  week.  It  will  often  be  found  diffi- 
cult to  enter  the  canal,  but  slow  and  careful  insertion,  with  gradual  ro- 
tation, will  allow  the  tissues  to  accommodate  themselves  without  surgical 
trauma.  Immediately  following  the  dilatation  of  the  external  auditory 
meatus,  there  will  be  a  marked  injection  of  the  drumhead — acute  myrin- 
gitis— which  is  readily  seen  with  the  myringoscope.  The  active  hyper- 
emia thus  produced  flushes  the  tympanic  membrane  and  ossicular  chain, 
breaking  up  the  low  grade  ossicular  synovitis,  tightening  the  over- 
relaxed  drumhead,  and  releases  the  impingement  of  the  lymph  drainage 
of  the  external  auditory  canal  and  membrana  tympani. 

The  bimanual  treatment  as  originated  by  Dr.  F.  P.  Millard— dila- 
tation of  the  pharyngeal  orifice  of  the  Eustachian  tube  and  external 
auditory  meatus— as  reported  in  the  Journal  of  the  American  Osteopathic 


208 


Lymphatics 


Plate  LVI.  Posterior  nasal  spaces  and  Ijonph  drainage  of  muscles  of  pal- 
ate and  pharynx.  (1)  Levator  veli  palatini;  (2)  tensor  veli  palatini;  (3) 
pharjTigo  palatinus;  (4)  stylo  pharyngeu?;  (5)  digastricus. 


Finger  Surgery 


209 


Plate  LVII.  Musculature  of  the  pharyngeal  orifice  of  the  Eustachian  tube 
and  lymph  drainage  of  the  palate.  (1)  Superior  constrictor  of  the  phar- 
ynx; (2)  salpingopharyngeus;  (3)  levator  veli  palatini;  (4)  pharj'ngo- 
palatinus;  (5)  tubercle  of  Gerlach  (tube  tonsil).  During  the  act  of  de- 
glutition, and  as  the  soft  palate  elevates,  the  tube  tonsil  comes  forward 
and  override-;'  the  Eustachian  orifice,  thereby  preventing  the  regurgitation 
of  foreign  substances  into  the  Eustachian  canal — epiglottis  of  the  tube. 


210  Lymphatics 

Association    (July,    1918),    is   now   used  by   the   writer,    and    is  very 
efficacious  in  the  management  of  catarrhal  deafness.     (Plate  54) . 

The  Eustachian  Lymphatics 

The  pharjmgeal  orifice  of  the  Eustachian  tube  is  situated  on  the 
lateral  wall  of  the  nasopharynx,  nearly  on  a  level  with  the  horizontal 
prolongation  of  the  inferior  turbinate  bone  (turbinate  body).  It  is  an 
oval  depression,  with  the  appearance  of  a  vertical  slit,  and  measures 
about  two-thirds  of  an  inch  in  diameter.  Numerous  glands  open  into 
the  tube  near  the  orifice,  and  there  also  exists  on  its  posterior  lip  a  con- 
siderable amount  of  adenoid  tissue,  which  constitutes  the  Eustachian 
cushion  ( 'tube  tonsil  of  Gerlach").  This  adenoid  mass  is  continuous 
with  that  of  the  nasopharynx  (Waldeyer's  ring),  and  is  well  developed 
in  the  early  periods.     (Plate  55). 

The  muscles  which  open  and  close  this  slit-like  orifice  are  covered 
with  mucous  membrane,  and  form  anteriorly  the  plica  salpingopharyngeal 
and  the  plica  salpingopalatine,  which  descend  respectively  from  the 
lower  end  of  the  Eustachian  cushion  and  from  the  anterior  border  of  the 
Eustachian  orifice  to  the  soft  palate  and  nasopharynx.     (Plate  56). 

The  lumen  of  the  cartilaginous  portion  of  the  Eustachian  tube  is 
entirely  dependent  on  the  proper  relation  of  the  muscles  and  tube  ton- 
sil. Between  the  tube  tonsil  and  posterior  wall  of  the  pharynx  is  a  re- 
cess— fossa  of  Rosenmuller — which  is  subject  to  great  individual  varia- 
tions in  size,  and  is  rich  in  glandular  tis.sue.  Chronic  nasopharyngeal 
catarrhs  often  give  rise  to  cystic  hypertrophy  of  the  adenoid  tissue  and 
the  formation  of  large  gaps  (pus  pockets)  and  bridge-like  bands  in  the 
Rosenmuller  fossa,  which  may  interfere  with  the  function  of  the  tube 
tonsil.  Recent  research  has  demonstrated  conclusively  that  the  Eusta- 
chian cushion  (tube  tonsil  of  Gerlach)  is  the  epiglottis  of  the  pharyngeal 
orifice  of  the  Eustachian  tube.  (Plate  57).  During  the  act  of  deglutition, 
and  as  the  soft  palate  elevates,  the  tube  tonsil  comes  forward  and  over- 
rides the  Eustachian  orifice,  thereby  preventing  the  regurgitation  of 
foreign  substances  into  the  Eustachian  canal. 

In  the  treatment  of  catarrhal  deafness  it  was  found,  in  many  in- 
stances, that  hypertrophy  of  the  floor  of  the  nasopharynx  (soft  palate) 
produced  a  recess  at  the  pharyngeal  orifice  of  the  Eustachian  tube,  which, 
being  filled  with  catarrhal  exudates,  functioned  quite  similar  to  a 
"plumber's  trap,"  interfering  with  ventilation  and  drainage  of  the  mid- 
dle ear.  Bearing  in  mind  these  anatomopathological  conditions,  it  is 
readily  seen  that  digital  dilatation  of  the  pharj'ngeal  orifice  of  the  Eusta- 
chian tube,  digital  curettage  of  the  Rosenmuller  fossa,   and  springing 


Finger  Surgery 


211 


I'LAiK  LVIII.  "Lateral  technic.-'  The  right  forefinger  is  dilating  the  right 
Eustachian  orifice,  and  illustrating  the  disadvantages  of  this  manipula- 
tion. The  cross  technic  is  much  easier,  and  will  not  tear  the  plicas  or 
produce  granulation  tissue  within  the  canal. 


212 


Lymphatics 


Plate  LIX.  "Cross  technic."  The  forefinger  of  the  right  hand  is  dilat- 
ing the  pharyngeal  orifice  of  the  left  Eustachian  canal,  with  the  patient 
in  a  recumbent  position.  By  turning  this  illustration  upside  down,  the 
technic  will  be  mere  easily  understood.  This  has  many  advantages 
over  the  "lateral  technic" — left  orifice  with  the  left  finger,  etc. 


Finger  Surgery  213 

the  soft  palate  (downward  and  forward)  will  release  the  impingement  of 
the  Eustachian  lymphatics,  drain  the  pus-pockets  within  the  Rosenmul- 
ler  fossa,  and  re-establish  the  normal  ventilation  and  drainage  of  the  tym- 
panum. 

Finger  Surgery  of  the  Eustachian  Lymphatics 

Clinical  experience  has  demonstrated  that,  in  order  to  reach  the 
pharyngeal  orifice  of  the  Eustachian  tube  of  the  same  side — i.  e.,  the 
right  orifice  with  the  right  finger  and  the  left  orifice  with  the  left  finger 
(lateral  technic) — owing  to  the  lost  motion,  purchase  power,  and  lev- 
erage caused  by  the  flexing  of  the  phalanges  and  wrist-joint,  it  was  very 
difficult  in  many  instances  to  dilate  the  pharyngeal  orifice,  but  this  con- 
dition could  be  easily  overcome  by  using  a  "  cross  technic. "  (Plates  58, 59) 

To  dilate  the  right  Eustachian  orifice,  the  left  forefinger  is  passed 
behind  the  uvula  upward  and  backward  into  the  nasopharynx.  The 
wrist-joint  and  phalanges  being  held  rigid,  the  weight  of  the  operator's 
arm  will  force  the  tip  of  the  first  phalanx  into  the  pharyngeal  orifice  of 
the  Eustachian  tube.  This  cross  technic  will  permit  a  much  easier  dila- 
tation of  the  orifice  without  a  tear  in  the  plicas,  which  very  often  occurs 
in  the  "lateral  technic,"  and  thus  avoid  the  accumulation  of  granula- 
tion tissue  within  the  cartilaginous  portion  of  the  Eustachian  tube, 
which  retards  the  results  of  the  operative  procedure.  The  fossa  of  Rosen- 
muller  should,  however,  be  cleaned  with  the  "lateral  technic,"  and  in- 
cidentally I  may  remark  that  Ballenger  (1914  edition)  in  connection 
with  this  point  uses  the  following  language  on  page  684 : 

"Thomas  H.  Brunk  first,  and  later  W.  S.  Bryant,  called  attention 
to  the  presence  of  granulation  tissue  and  adhesive  bands  in  the  Rosen- 
muller's  fossa,  claiming  that  their  removal  with  the  finger  introduced 
through  the  mouth  relieved  tubal  catarrh  and  deafness.  Indeed,  this 
opinion  is  attracting  considerable  attention,  as  the  removal  of  these 
bands  has  in  numerous  cases  been  followed  by  improvement.  The  ad- 
hesive  bands  are  frequently  present,  and  should  be  searched  for  more 
frequently  than  has  been  customary. " 

On  page  687  he  says : 

"If  adhesive  bands  are  present  in  the  RosenmuUer's  fossa,  the  index 
finger  of  the  right  hand  should  be  introduced  through  the  mouth  and  the 
right  fossa  thoroughly  curetted  with  the  nail.  The  left  index  finger 
should  be  used  to  curette  the  left  fossa. " 

The  operator,  when  manipulating  the  soft  palate,  should  avoid 
touching  the  posterior  pharyngeal  wall,  which,  when  disturbed,  influ- 
ences   nausea  and  gagging,  being  the  gagging  center.     The  forefinger 


214 


Lymphatics 


Plate  LX.  Eustachian  orifices,  with  posterior  aspect  of  the  turbinals,  and 
their  relation  to  the  oral  lymphatics.  As  the  palate  is  sprung  downward 
and  forward,  the  traction  is  exerted  upon  the  pharyngeal  orifices  and 
posterior  nasal  spaces. 


Finger  Surgery 


215 


Plate  LXI.  The  forefinger  is  springing  the  soft  palate,  downward  and  for- 
ward, forming  an  acut<?  angle  with  the  hard  palate.  The  operator  should 
avoid  touching  the  posterior  pharyngeal  wall — the  gagging  center. 


216  Lymphatics 

should  be  passed  to  the  lateral  aspect  of  the  uvula,  then  gently  behind 
the  velum  pendulum  palati,  and  upward  and  backward  into  the  naso- 
pharynx. While  forcibly  springing  the  soft  palate,  the  traction  should 
be  exerted  upon  the  lateral  muscular  portion,  and  not  the  raphe  of  the 
velum.  Traction  exerted  upon  the  uvula  or  raphe  of  the  velum  will  have 
little,  if  any,  effect  upon  the  walls  of  the  nasopharynx.  The  muscu- 
lar portion  should  be  forcibly  sprung  downward  and  forward,  forming  an 
acute  angle  with  the  hard  palate,  and  held  in  this  position  a  minute  or 
two.  This  will  influence  the  lymph  drainage  and  eliminate  the  passive 
congestion  within  the  lateral  nasopharyngeal  walls.     (Plates  60,  61,  62). 

Lymphatics  of  the  Nasal  Cavity 

The  lymphatics  of  the  nasal  cavity  form  an  irregular  network  in  the 
superficial  part  of  the  mucous  membrane,  and  can  be  injected  from  the 
subdural  or  subarachnoid  space.  The  larger  vessels  are  directed  back- 
ward toward  the  choanae  and  are  collected  into  two  trunks,  of  which 
the  larger  passes  to  a  lymphatic  gland  in  front  of  the  axis  vertebra  and 
the  smaller  to  one  or  two  glands  situated  near  the  great  cornu  of  the 
hyoidbone.     (Cunningham). 

Most  of  the  lymphatics  of  the  nasal  fossa  enter  the  retropharyngeal 
glands  placed  behind  the  phaiynx,  in  front  of  the  rectus  capitis  anticus 
major,  and  hence  retropharyngeal  abscess  may  arise  in  consequence  of 
diseases  of  the  nose.  Other  lymphatics  go  to  the  submaxillary,  parotid, 
and  upper  deep  cervical  lymph  glands,  and  it  is  common  to  find  these 
enlarged  in  nose  affections,  especially  in  those  of  a  scrofulous  nature. 
The  lymphatics  of  the  nose  also  communicate  with  those  of  the  meninges 
through  the  cribriform  plate.     (Treves) . 

Finger  Surgery  of  the   Nasal   Lymphatics 

Digital  dilatation  of  the  posterior  nares  by  means  of  the  index  finger, 
and  anterior  nares  with  the  little  finger,  is  very  efficacious  in  the  re- 
establishment  of  the  lymphatic  drainage  of  the  nasal  cavity.  The  writer 
uses  this  technic,  in  addition  to  structural  adjustments,  in  the  treatment 
of  catarrhal  deafness,  hay  fever,  otitis  media,  pharyngitis,  and  other 
diseases  of  the  upper  respiratory  tract. 

Technic — Prepare  the  little  finger  by  trimming  the  nail  below  the 
cushion  and  lubricate  with  some  mild,  oily  antiseptic  (KY)  lubricant, 
or  Williams'  fluid  is  very  good.  A  five  per  cent,  solution  of  holocain  or 
alypin  in  adrenalin  chloride  1 :1000  will  very  readily  anesthetize  the  tis- 
sues, and  the  finger  can  be  passed  with  very  little  discomfort  to  the  pa- 
tient. The  anterior  and  posterior  nares  are  sprayed  with  either  of  these 
solutions  and  allowed  to  remain  from  ten  to  fifteen  minutes. 


Finger  Surgery 


217 


Plate  LXII.  Finger  surgery  of  the  oral  lymphatics.  The  forefinger  of  the 
right  hand  is  passed  behind  the  uvula,  upward  and  backward,  into  the 
nasopharynx,  and  the  soft  palate  is  sprung,  downward  and  forward, 
being  held  in  this  position  from  one  to  two  minutes. 


218 


Lymphatics 


Plate  LXIII.  Finger  surgery  of  the  sphenopalatine  ganglion.  The  fore- 
finger is  passed  behind  the  uvula,  upward  and  backward,  into  the  naso- 
pharj'nx,  and  forced  as  far  as  possible  into  the  posterior  nasal  spaces. 
The  ganglion  is  manipulated  with  the  tip  of  the  first  phalanx. 


Finger  Surgery  219 

When  inserting  the  Httle  finger  into  the  anterior  nares  (palmar  sur- 
face upward) ,  the  first  phalanx  should  be  directed  upward  and  backward 
into  the  olfactory  area,  and  by  a  gentle,  passive  manipulation  the  "epi- 
naris"  will  be  dilated.  The  finger  should  then  be  lowered  and  directed 
back  into  the  posterior  nares  and  rotated  several  times,  thereby  relax- 
ing the  lateral  tissues  of  the  nasal  cavity,  which  will  release  the  obstruc- 
tions to  the  lymph  drainage.  To  dilate  the  posterior  nasal  spaces,  the 
index  finger  of  either  hand  should  be  introduced  through  the  mouth, 
behind  the  uvula,  upward  and  backward  to  the  vomer.  The  finger 
should  be  forced  as  far  as  possible  into  the  posterior  nasal  spaces,  while 
in  situ  the  posterior  aspect  of  .the  inferior  turbinate  (turbinate  body) 
may  be  manipulated.  The  functional  hypertrophy  of  this  turbinal  is, 
in  many  instances,  the  cause  of  nasal  stenosis. 

Sphenopalatine  Ganglion. — This  ganglion  may  be  manipulated 
while  dilating  the  posterior  nasal  spaces.  Meckel's  ganglion  is  situated 
in  the  tissue  which  is  directly  beneath  the  nail  of  the  operator's  forefinger 
— patient  in  the  recumbent  position  and  operator's  index  finger  forced  as 
far  as  possible  into  the  posterior  nasal  spaces.  By  pressing  the  nail  of 
the  forefinger  firmly  downward,  the  purchase  power  will  be  referred  to  the 
ganglion,  which  is  only  a  few  millimeters  beneath  the  mucosa.  (Plate  63) . 
This  technic  has  proved  very  efficacious  in  the  treatment  of  tic  dou- 
loureux, nasopharj^ngitis,  hay  fever,  catarrhal  deafness,  asthma,  and 
chronic  bronchitis.  By  a  study  of  its  anatomical  relations  it  is  readily 
seen  that  the  attention  of  this  important  ganglion  will  clear  up  many 
of  the  difficulties  in  the  treatment  of  the  lymph  drainage  of  the  nasal 
cavity  and  upper  respiratory  tract. 

Lymph  Drainage  of  the  Oral  Cavity 

The  lymphatic  channels  of  the  oral  cavity  pass  into  the  lymphatic 
glands  situated  at  the  angle  of  the  jaw,  and  this  accounts  for  the  enlarge- 
ment of  the  glands  here  in  certain  affections  of  the  nasopharynx.  The 
Ij^mphoid  tissue  is  in  scattered  nodules,  except  on  the  lateral  walls  just 
behind  the  posterior  pillars  of  the  fauces,  where  a  chain  of  lymph  nodules 
runs  vertically,  connecting  with  the  lymphoid  tissue  along  the  lateral 
walls  of  the  nasopharynx.     (Plate  64). 

The  mass  in  the  neck,  often  mistaken  for  an  enlarged  tonsil,  is  formed 
of  enlarged  glands,  situated  near  the  tip  of  the  great  cornu  of  the  hyoid 
bone,  and  overlying  the  internal  jugular  vein.  These  glands  receive  the 
tonsillar  lymphatics,  and  are  almost  invariably  enlarged  in  all  tonsil 
affections.  The  oral  lymphatics  pass  chiefly  to  the  upper  cervical  glands. 
Those  from  the  upper  part  of  the  posterior  wall  join  a  few  postphar\'ngeal 


220 


Lymphatics 


Plate  LXIV.  Lymphatics  of  the  uvula,  tonsils,  and  pillars  of  the  fauces, 
and  their  relation  to  the  lymph  glands  of  the  submaxillary  and  hyoid 
areas.  The  outlines  in  white  are  the  structures  treated  by  finger  sur- 
gery in  the  management  of  voice  alteration,  nasopharyngitis,  hay  fever, 
and  catarrhal  deafness.  Springing  the  soft  palate,  downward  and  for- 
ward, will  re-estabhsh  the  lymph  drainage  of  the  nasopharynx  and  pos- 
terior nasal  spaces. 


Finger  Surgery 


221 


Plate  LXV.     Diagram  of  the  submaxillary  glands  and  their  relation  to  the 
tonsillar  lymphatics.     The  forefinger  is  milking  the  tonsillar  crypts. 


222  Lymphatics 

glands,  which  are  found  on  each  side  of  the  pharynx.  The  lymphatic 
glands  of  the  neck  drain  the  teeth,  tonsils,  adenoids,  pharynx,  and  the 
mastoid  region. 

Finger  Surgery  of  the  Oral  Lymphatics 

The  faucial  tonsils  are  only  a  part  of  the  lymphoid  structures  of  the 
pharynx,  and,  owing  to  the  continuity  of  this  glandular  chain,  focal  in- 
fections in  neighboring  lymphatic  nodules  are  often  the  exciting  factors 
in  tonsiUitis.     (Plate  65). 

To  demonstrate  that  the  pharynx  is  a  source  of  these  infections,  I 
shall  briefly  review  the  anatomical  relations  of  the  lymphoid  tissues  in 
this  region — the  faucial  tonsils,  globular  masses,  situated  between  the 
anterior  and  posterior  pillars  of  the  fauces,  on  either  side  of  the  oro- 
pharynx; the  mass  of  lymphoid  tissue  on  the  posterior  pharyngeal  wall, 
commonly  called  adenoids;  the  lingual  tonsils,  situated  at  the  base  of 
the  tongue,  on  either  side  of  the  median  line;  and  the  lymphatic  nodules 
on  the  posterior  and  lateral  walls  of  the  pharynx.  This  group  of  tonsils 
makes  up  the  so-called  'Waldeyer's  ring,"  and,  to  my  mind, this  is  the 
"Roman  wall"  of  the  throat,  which  acts  as  a  protective  agent  to  the 
respiratory  tract  during  early  childhood.  Bearing  in  mind  the  four 
cardinal  factors  in  bacteriology — namely,  lowered  resistance,  avenue  of 
entrance,  virulence,  and  number — it  is  readily  seen  that  any  break  in 
this  wall  of  lymphatic  nodules  exposes  the  system  to  almost  everything 
on  the  infectious  disease  calendar. 

In  considering  this  subject  an  effort  is  made  not  so  much  to 
direct  attention  to  anything  new  in  oropathology,  but  especially  to  con- 
sider the  avoidance,  as  far  as  possible,  of  unnecessary  surgery  upon  use- 
ful structures,  and,  most  of  all,  to  urge  greater  care  in  the  matter  of 
tonsillar  diagnosis.     (Plates  66,  67). 

Masland,  reporting  his  tonsillar  research,  says:  "We  see  in  the  tonsil 
in  the  early  y-ears  of  life  a  startling  picture  of  developmental  change. 
In  normal  children,  in  connection  with  the  lingual  tonsils  and  the  naso- 
pharyngeal adenoids,  this  pharj'ngeal  ring  of  lymphatics,  "Waldeyer's" 
is  always  of  considerable  size.  Prominent  in  early  years,  it  undergoes 
a  retrogressive  change,  but  there  remains  always  some  lymphatic  struc- 
ture throughout  the  ring.  The  thought  has  come  to  me  of  the  possible 
interrelation,  either  or  both  interactivation  and  intcrinhibition,  be- 
tween this  structure  and  the  thymus  and  the  thyroid,  particularly  in  the 
early  years  of  life.  How  far  this  has  been  investigated,  I  do  not  know. 
Can  we  deny,  then,  that  this  phar^'ngeal  lymphatic  ring,  over  which  pass 
all  ingested  liquid,  solid,  or  gaseous  material,  does  perform  a  vital  func- 
tion in  the  body  economy?" 


Finger  Surgery 


223 


Plate  LXVI.  Finger  surgery  of  the  tonsillar  lymphatics  in  the  treatment 
of  chronic  tonsillitis.  The  forefinger  is  separating  the  plica  triangularis 
and  anterior  pillar  of  the  faucep  from  the  parenchvma,  thereby  releas- 
ing the  impingement  of  the  subdivisions  of  the  tonsillar  artery  and  ven- 
ous drainage. 


224 


Lymphatics 


Plate  LXVII.     Finger  surgery  of  the  post-tonsillar  space.     The  forefinger 
is  separating  the  posterior  pillar  of  the  fauces  from  the  parenchyma. 


Finger  Surgery  225 

Epiglottis  op  the  Tonsil.— The  function  of  the  plica  triangularis 
can  be  demonstrated  very  nicely  by  the  insertion  of  a  Holmes  naso- 
pharyngoscope  into  the  side  of  the  mouth  and  observing  the  manipula- 
tions of  the  plica  and  pillars  of  the  fauces  during  the  act  of  swallowing. 
During  the  act  of  mastication  and  deglutition  the  plica  triangularis  is 
stretched  across  the  tonsil,  thereby  preventing  the  food  from  packing 
the  crypts.  My  experiments  conclusively  showed  that  the  plica  triangu- 
laris had  a  "shutter  movement" — it  would  fold  back  into  the  anterior 
pillar  of  the  fauces  to  allow  the  milking  process  of  the  crypts  and  then 
quickly  stretch  across  the  tonsil  as  the  food  approached  it.  The  plica 
triangularis  is  unquestionably  the  "epiglottis  of  the  tonsil,"  and,  unless 
diseased,  should  not  be  removed  in  any  instance.     (Plate  68). 

Technic. — The  author  uses  what  is  termed  a  "suspension  technic," 
by  which  the  tonsil  is  lifted  from  its  infratonsillar  fossa  and  held  in  this 
position  for  a  minute  or  two.  (Plate  69).  This  is  easily  done  with  no 
discomfort  to  the  patient,  by  passing  the  index  finger  into  the  mouth  and 
following  the  side  of  the  tongue  to  the  lower  pole  of  the  tonsil.  The 
finger  should  not  touch  the  posterior  pharyngeal  wall — the  gagging  cen- 
ter— and  the  manipulation  should  be  restricted  to  the  lower  pole.  With 
the  cushion  of  the  index  finger  the  tonsil  is  gradually  raised  and  held  in 
suspension  for  a  minute  or  two.  In  the  bimanual  manipulation  counter 
pressure  is  made  on  the  outside  of  the  throat,  at  the  submaxillary 
area,  with  the  index  finger  of  the  opposite  hand.  The  lingual  tonsils 
and  varix,  situated  at  the  base  of  the  tongue,  may  be  treated  with 
the  same  finger,  not  forgetting,  however,  to  avoid  the  gagging  center 
on  the  posterior  pharyngeal  wall.  This  technic  will  re-establish  the 
lymph  drainage,  function  of  the  plica  triangularis,  and  milking  process 
of  the  tonsillar  crypts. 

The  Lymph  Drainage  of  the  Larynx 

The  lymphatics  of  the  larynx  are  of  much  importance  with  refer- 
ence to  voice  alteration.  The  lymphatics  above  the  ^ords  empty  into 
two  or  three  trunks  in  the  aryepiglottic  folds,  which  pass  through  the 
thyrohyoid  membrane  to  the  glands  on  the  internal  jugular  vein  at  the 
level  of  the  upper  border  of  the  thyroid  cartilage.  A  small  gland  is 
sometimes  present  on  the  thyrohyoid  membrane,  but  appears  seldom  to 
be  infected.  The  lymphatics  below  the  cords  leave  the  air-tube  above 
and  below  the  cricoid  and  empty  into  the  lower  deep  cervical  glands 
along  the  jugular  vein.  Some  pass  with  the  inferior  laryngeal  vessels 
to  a  peritracheal  chain  of  glands;  several  minute  glands  may  be  found  on 
the  cricothyroid  membrane  and  on  the  trachea,  especially  about  the 


226 


Lymphatics 


Plate  LXVIII.  Plica  triangularis  and  its  relation  to  the  faucial  tonsils. 
The  plica  is  attached  to  the  anterior  pillar,  and  during  the  act  of  masti- 
cation it  is  stretched  across  the  tonsil,  thereby  preventing  the  food  from 
packing  the  crypts — epiglottis  of  the  tonsil.  In  this  illustration  the 
plicas  are  functioning,  and  the  tonsils  can  be  observed  behind  this  cur- 
tain effect. 


Finger  Surgery 


227 


Plate  LXIX.  Finger  surgery  of  the  tonsillar  lymphatics  (suspension  tech- 
nic).  The  forefinger  of  the  lef!  hand  is  lifting  the  left  tonsi'.  from  its 
infratonsillar  fossa  and  holding  it  in  suspension  for  a  minute  or  two. 
This  manipulation  should  be  restricted  to  the  lower  pole,  and  the  oper- 
ator should  avoid  touching  the  posterior  pharyngeal  wall — the  gagging 
center. 


228  Lymphatics 

thyroid  isthmus,  but  are  rarely  involved.  The  vocal  cords  themselves 
lie  between  these  two  systems;  their  lymphatics,  which  are  remarkablj-- 
small  and  scanty,  pass  to  the  upper  set  of  vessels. 

Technic. — The  index  and  second  fingers  are  passed  over  the  pos- 
terior aspect  of  the  tongue — avoiding  the  gagging  center — and  directly 
into  the  epilarynx.  The  hyoid  is  treated  by  a  rotary  movement  of  the 
fingers  and  the  epiglottis  by  a  stretching  of  the  cpiglottidean  ligaments. 
The  middle  ligament — a  prominent  mesial  fold  of  mucous  membrane — 
is  often  found  to  be  indurated  and  resembling  a  tumefaction.  A  few 
treatments  at  this  area  will  work  wonders  in  ''voice  failures"  and  tickling 
throats. 

As  the  fingers  are  withdrawn,  the  structures  of  the  epilarynx  and 
those  at  the  base  of  the  tongue  are  treated  by  a  forward  forcible  manual 
traction  upon  the  posterior  aspect  of  the  tongue.  The  cushions  of  the 
index  and  second  fingers  are  placed  just  beneath  the  varix  and  lingual 
tonsils,  and  with  this  "purchase  power"  the  tongue  is  forcibly  lifted  up- 
ward and  forward  and  held  in  this  position  for  a  minute  or  two,  which 
will  re-establish  the  lymph  drainage  of  the  larynx,  varix,  and  lingual  ton- 
sils. The  external  aspect  of  the  larynx  is  supported  by  the  opposite 
hand,  bringing  counter  pressure  and  raising  the  larynx  as  the  tongue 
is  brought  forward,  the  opposite  hand  being,  of  course,  on  the  outside 
of  the  throat.  This  is  one  case  where  anesthesia,  of  any  sort,  is  contra- 
indicated,  as  the  peripheral  stimulation  excited  by  the  digital  insertion 
and  manipulative  procedure  is  an  important  factor  in  the  treatment.  If 
the  tissues  are  anesthetized,  they  lose  this  stimulating  effect,  and  the 
treatment  will  not  be  as  efficacious.  This  local  manipulation  of  the 
larv'nx  has  worked  wonders  in  the  treatment  of  acute  and  chronic  laryn- 
gitis, many  vocal  celebrities  and  famous  orators  have  been  returned  to 
their  professions  by  this  treatment. 


JOHN  H.  BAILEY,  D.  O. 
Philadelphia,  Pa. 


CHAPTER  FOURTEEN 

A  CONSIDERATION  OF  THE  LYMPHATICS  OF  THE 

EYE,  EAR,  NOSE  AND  THROAT  IN  HEALTH 

AND  DISEASE 

John  H.  Bailey,  D.  O.,  Philadelphia,  Pa. 
Lymphatics  of  the  Nose 

Except  in  the  olfactory  area,  the  nasal  mucous  membrane  is  char- 
acterized by  ciliated  columnar  epithelium,  interspersed  with  goblet 
cells  that  secrete  mucus.  Beneath  the  basement  membrane  of  the  epi- 
thelium is  a  layer  of  adenoid  tissue  that  is  particularly  plentiful  in  chil- 
dren, and  beneath  this  again  is  a  layer  of  mucous  and  serous  glands 
of  variable  sizes  with  ducts  opening  upon  the  surface.  The  fibrous 
stroma  is  dense  in  the  deeper  parts  and  forms  the  periosteum  which  is 
not  firmly  attached  to  the  bone,  but  is  quite  easily  peeled  off.  This 
must  be  guarded  against.  The  cilia  or  hairs  of  the  columnar  cells  act 
as  scavengers,  sweeping  awaj^  debris,  dust,  bacteria,  etc..  that  have  been 
trapped  by  the  moist  surfaces  during  the  whirling  of  the  inspired  air. 
When  the  columnar  epithelium  is  destroyed  by  atrophy,  accident,  elec- 
tricity, or  operation,  it  does  not  form  again,  but  is  replaced  by  squamous 
epithelium  which  does  not  moisten  and  sweep  away  the  debris,  resulting 
in  the  constant  forming  of  crusts  within  the  nose. 

The  mucous  membrane  of  the  nose  is  continuous  anterior^  into 
the  frontal,  and  maxillary  sinuses  and  the  anterior  ethmoid  cells,,  pos- 
teriorly into  the  posterior  ethmoid  cells  and  the  sphenoid  sinus,  and  it 
furthermore  continues  up  through  the  lachrymal  duct  and  is  reflected 
over  the  eyelids  and  eyeballs  as  the  conjunctiva.  Posteriorly,  also,  it 
is  continuous  with  the  mucous  membrane  of  the  pharynx,  Eustachian 
tube,  middle  ear,  inner  lining  of  the  tympanum,  mastoid  cells  and  ac- 
cessory cavities  of  the  ear;  also  into  the  larynx,  trachea,  bronchi  and 
alveoli;  also  into  the  esophagus  and  on  through  the  entire  gastro-intes- 
tinal  tract,  the  pancreatic  duct,  the  common  bile  duct  and  into  the  pan- 
creas, liver  and  other  accessory  gastro-intestinal  glands,  into  the  intes- 
tines, appendix,  colon,  and  rectum.  Hence  any  infection  of  the  mu- 
cous membrane  of  the  nose  can  involve  almost  any  organ  in  the  body. 

The  nasal  lymphatics  lie  just  beneath  the  epithelium,  forming  a 
diffuse  adenoid  tissue,  infiltrated  with  lymph-corpuscles,  which,  no 
doubt,  helps  to  account  for  the  marvelous  destruction  of  bacteria  by 
the  nasal  mucous  membrane.     The  lymph  is  drained  partly  into  the 

—231— 


232  Lymphatics 

retro-pharyngeal  glands  in  the  upper  lateral  pharyngeal  wall  in  front 
of  the  axis,  and  partly  into  one  or  two  glands  which  lie  near  the  great 
cornu  of  the  hyoid  bone,  and  from  all  of  these  into  the  upper  deep  cervical 
glands.  Obstruction  to  lymph  drainage  reduces  the  nasal  immunizing 
power  and  leaves  the  body  an  easy  prey  to  any  air-borne  infection. 

Tuberculosis  Prevented  by  Healthy  Nose 

It  has  been  shown  by  St.  Clair,  Thomson  and  Howlett,  that  whereas 
the  front  of  the  nose  contains  numerous  microorganisms,  none  are  to 
be  found  in  the  posterior  regions  of  80%  of  normal  noses;  or,  more  strict- 
ly, none  which  are  capable  of  growth  upon  the  ordinary  laboratory  media. 
For  practical  purposes,  at  all  events,  one  may  say  that  inspired  air  which 
has  passed  through  the  nose  is  clean  as  well  as  moist,  and  that  a  healthy 
man  possesses  in  that  organ,  a  protective  apparatus  which  relieves  his 
lungs  of  all  sources  of  danger,  so  far  as  the  air  inhaled  through  the  nose 
is  concerned. 

Air-borne  bacteria  gain  entrance  to  the  body  by  way  of  the  respira- 
tory tracts.  If  the  nose  is  normal  there  will  be  no  tuberculosis.  If  the 
public  press  would  start  now  and  educate  the  masses  as  to  the  proper 
use  of  the  nose,  and  if  in  all  schools  of  learning,  public  and  private,  time 
were  devoted  to  educating  the  rising  generation  to  the  point  of  using  the 
nose  properly  and  thus  keep  it  in  good  condition,  we  would  have  no  great 
white  plague,  nor  any  other  infectious  diseases.  For  years  we  have  had 
it  drilled  into  our  heads  by  the  medical  profession  of  how  important  our 
lungs  are  and  what  to  expect  if  tuberculosis  enters  them.  How  can  the 
lungs  develop  if  the  breathing  apparatus,  nose,  etc.,  is  not  working  prop- 
erly? 

Catarrh,  deafness,  headache,  bronchitis,  gastritis,  lack  of  develop, 
ment  of  body  and  mind,  and  a  host  of  other  abnormal  conditions,  are  in 
the  vast  majority  of  cases  primarily  due  to  improper  breathing. 

Every  attack  of  smallpox,  typhoid  fever,  acute  articular  rheuma- 
tism, epidemic  influenza  (la  grippe),  erysipelas,  measles,  diphtheria,  in- 
fantile paralysis,  cerebrospinal  meningitis,  tonsillitis,  bronchitis,  pneu- 
monia, hay  fever,  catarrh  and  other  acute  infections,  begins  with  a  cold 
in  the  head. 

Tell  your  patients  to  bring  their  children  in  for  treatment  as  soon 
as  they  have  the  first  signs  of  a  cold.  Nearly  all  acute  infectious  dis- 
eases begin  with  "a  cold  ;n  the  head,"  and  they  never  develop,  if  the 
"cold"  is  treated  at  once.  Medical  men  will  laugh  at  this  statement. 
They  cannot  do  anything  for  a  cold.  Yet  hundreds  of  cases  are  on  rec- 
ord of  children  that  have  entirely  escaped  children's  diseases  because 


In  Health  and  Disease  233 

the  defensive  mechanism  of  the  nose  is  normal  and  hundreds  of  cases  of 
children's  diseases  are  aborted  every  year  when  the  nose  is  normalized 
and  kept  so.  The  first  appearance  of  a  watery  discharge  from  the  nose 
is  the  danger  signal. 

Suppurative  Rhinitis  a  Serious  Symptom 

There  is  pus  in  the  sinuses  in  the  later  stages  of  acute  coryza;  in 
chronic  nasal  catarrh;  accompanying  syphilitic,  gonorrheal  or  tubercu- 
lous processes  in  the  nose;  during  diphtheria,  influenza,  and  the  other 
specific  exanthematous  fevers;  and  in  a  number  of  rare  conditions  which 
it  is  well  to  look  up  in  Ballenger  and  other  authorities.  This  pus  is 
discharged  into  the  nasal  passages  and  it  is  essential  that  both  nasal 
cavities  be  thoroughly  examined  in  a  direct  light  by  means  of  a  specu- 
lum  and  head  mirror  to  determine  the  source  of  the  pus,  specimens  be- 
ing taken  for  bacteriological  examination  when  necessary. 

The  frontal  sinus,  maxillary  sinus,  and  anterior  ethmoidal  cells 
open  into  the  middle  meatus  through  the  infundibulum  and  semilunar 
hiatus  and  drain  on  to  the  upper  surface  of  the  inferior  turbinate. 

The  posterior  ethmoidal  cells  open  into  the  superior  meatus  and 
drain  onto  the  upper  surface  of  the  middle  tm'binate.  The  sphenoidal 
sinus  opens  into  the  upper,  back  corner  of  the  olfactory  fissure,  between 
the  septum  and  the  superior  turbinate. 

There  may,  however,  be  a  closed  empyema  in  any  cavity,  and  there 
is  also  great  variation  in  the  drainage,  from  normal  free  drainage  to 
closed  cavity.  Closed  pus  cavities  may  demand  operation.  Diagnosis 
is  by  transillumination,  or  X-ray.  There  is  danger  of  the  infection 
spreading  to  the  meninges  and  cranial  cavity.  The  accessory  sinuses 
are  usually  found  to  be  involved  in  chronic  rhinitis,  and  are  always  in- 
volved in  suppurative  rhinitis.  The  region  beneath  the  Middle  Turbi- 
nate is  called  the  storm  centre  because  the  anterior  group  of  nasal  ac- 
cessory sinuses  drain  into  this  region. 

Wonderful  Meciianlsm  of  Drainage  In  Normal  Sinuses 

When  normal  the  nasal  accessory  sinuses  are  capable  of  self-drain- 
age in  the  following  ways: 

1.  The  lining  mucous  membrane  is  composed  of  ciliated  columnar 
epithelium,  the  motion  wave  of  the  cilia  being  always  directed  to  the 
ostium,  or  opening  into  the  nasal  fossa,  and  the  quantity  of  secretion 
being  just  enough  to  keep  the  mucous  membrane  moist. 

2.  They  all  drain  toward  the  median  plane,  so  that  in  lying  with 
the  head  turned  to  one  side,  the  sinuses  in  the  upper  side  drain  more 


234  Lymphatics 

readily  with  aid  of  gravity  and  the  sinuses  on  the  lower  side  tend  to 
drain  more  slowly. 

3.  Each  sinus  drains  most  readily  when  the  position  of  the  head  is 
such  that  the  lowest  portion  of  the  sinus  is  its  ostium ;  namely : 

(a)  In  the  erect  position,  standing  or  sitting,  both  frontal  sinuses. 

(b)  On  lying  down  on  the  back,  both  maxillary  sinuses. 

(c)  On  lying  face  down,  forehead  lower  than  chin,  both  sphe- 
noidal sinuses. 

(d)  The  ethmoidal  cells  may  drain  directly  into  the  nasal  cavity, 
into  the  frontal  sinus  or  into  one  another,  and  their  drainage  may  there- 
fore be  simple  as  the  frontal,  or  it  may  be  very  complicated. 

The  Edwards  technique  is  today  proving  its  efficacy  in  the  hands  of 
osteopathic  physicians  all  over  the  country,  in  a  remarkable  variety  of 
eye,  ear,  nose  and  throat  conditions.  Not  only  the  profession  but  the 
public,  owes  Dr.  Edwards  a  debt  of  gratitude  for  the  wonderful  work 
that  he  has  done  along  this  line. 

The  connection  between  a  "cold  in  the  head"  and  the  acute  exan- 
themata, has  never  been  properly  brought  to  the  attention  of  the  public. 
You  should  post  yourself  thoroughly  on  this  point.  It  will  save  you 
many  a  patient  who  would  otherwise,  perhaps,  shift  to  an  allopath  with 
the  advent  of  acute  disease.  It  will  also  establish  you  as  an  authority 
in  the  minds  of  your  patients.  It  will  save  many  a  child  from  serious 
disease,  impairment  of  faculties,  distressing  sequelae,  and  even  untimely 
death.     Your  duty  is  plain. 

A  Normal  Pharynx  is  to  the  Child  What  a  Normal  Nose 
is  to  the  Adult 

(a)  Adenoid  tissue  is  connective  tissue  like  that  forming  the  lym- 
phatic glands.  It  consists  of  a  network  of  fibres  in  the  meshes  of  which 
lodge  lymphoid  cells.  Bear  in  mind,  that  in  early  years,  up  to  the  age 
of  puberty  and  in  some  cases  beyond  that  age,  the  child  depends  in  great 
part  on  the  adenoid  tissue  of  the  pharynx  to  protect  it  against  the  exan- 
themata, and  other  infections. 

(b)  As  the  child  approaches  adult  life  the  nose  takes  up  the  bur- 
den  when  the  adenoid  tissue  in  the  pharynx  atrophies.  It  is,  there- 
fore, of  prime  importance  in  children  that  the  arterial  blood  supply, 
the  venous  drainage  and  the  lymph  drainage  of  the  pharynx  be  thorough- 
ly free  and  unobstructed.  Any  obstruction  in  the  pharynx  will  obstruct 
the  lymph  drainage  from  the  nose,  will  react  on  the  vagus  and  other 
nerves  and  the  superior  cervical  sympathetic  ganglia  and  cause  a  variety 
of  distressing  symptoms  in  every  organ  of  the  body.     On  the  other  hand, 


In  Health  and  Disease  235 

there  is  scarcely  a  disease  of  any  consequence  in  which  the  pharynx  is 
not  involved.  It  may  be  inflamed  by  all  pathogenic  organisms,  whether 
borne  by  air,  food,  water,  blood  or  lymph,  may  show  mucous  patches, 
gummata,  cancer,  tubercle,  abscesses ;  is  involved  in  all  the  exanthemata, 
in  nasal  conditions,  in  nervous  conditions,  in  heart  disease,  in  kidney 
disease,  in  diabetes,  in  systemic  toxemias,  etc. 

When  children  are  threatened  with  any  of  the  exanthemata  there  is 
always  congestion  in  the  regions  draining  the  pharynx,  due  to  the  in- 
creased activity  of  the  phagocytes  destroying  the  invading  bodies,  coup- 
led with  muscular  contractures  and  bony  lesions  in  the  cervical  area, 
the  hyoid,  mandible,  clavicles,  etc.  As  long  as  the  drainage  is  free,  the 
child  does  not  contract  mumps,  measles,  scarlatina  or  any  of  the  exan- 
thematous  fevers.  It  is  only  when  obstruction  has  provided  the  invad- 
ing virus  with  a  suitable  culture  medium,  free  from  pure  blood,  that  dis- 
ease can  gain  ascendency  in  the  child's  pharynx,  nose,  lungs,  stomach, 
etc.  Always  examine  everj'  patient  for  obstruction  to  the  drainage  of 
the  pharynx  and  free  it  up  when  necessary. 

Drainage  of  the  Pharynx,  Nose  and  Ear 

The  retropharyngeal  lymphatic  glands  on  each  side  are  placed  in 
front  of  the  atlas  and  axis,  behind  the  upper  back  corner  of  the  pharynx, 
upon  the  rectus  capitis  anticus  major  muscle.  They  receive  lymph 
from  the  nasal  fossae  and  accessory  cavities,  the  nasopharynx  and  Eus- 
tachian tube  and  probably  the  middle  ear.  They  drain  into  the  internal 
group  of  upper  deep  cervical  glands,  which  lie  directly  upon  or  close  by 
the  outer  border  of  the  internal  jugular  vein  beneath  the  sternomastoid 
muscle  forming  a  chain  along  the  front,  side  and  back  of  the  internal 
jugular  vein  from  the  mastoid  process  of  the  temporal  bone  to  the  point 
where  the  omohyoid  crosses  the  common  carotid  artery  opposite  the 
cricoid  cartilage.  The  glands  of  the  internal  group  communicate  freely 
with  each  other  and  with  the  external  group  which  lies  behind  and  ex- 
ternal to  the  internal  jugular  vein  in  the  same  region,  draining  the  ex- 
ternal regions  of  the  side  and  back  of  the  head.  The  internal  group  re- 
ceives  lymph  from  the  retro-pharyngeal  glands,  mentioned  above,  and 
also  from  the  parotid,  subparotid,  submental  glands,  the  palatine 
tonsils  and  submaxillary  glands,  the  superficial  and  deep  anterior  cer- 
vical and  recurrent  glands,  and  from  the  nasal  fossae,  nasophar\'nx, 
soft  palate,  roof  of  the  mouth,  tongue,  larynx,  thyroid  gland,  trachea  and 
esophagus  (cervical  region);  in  a  word,  all  the  important  structures  on. 
within,  or  adjoining  the  mucous  membrane  of  ear,  nose,  phar>'nx  and 
cervical  portions  of  the  respiratory  and  digestive  tracts.     This  shows 


236  Lymphatics 

the  extreme  importance  of  free  drainage.  The  internal  group  terminates 
in  the  jugular  trunk,  which  on  the  right  side,  helps  to  form  the  right  l\Tn- 
phatic  duct  or  empties  directly  into  the  junction  of  the  internal  jugu- 
lar  and  subclavian  veins,  and  on  the  right  side  into  the  junction  of  the 
veins  or  into  the  thoracic  duct. 

Treatment  to  promote  drainage  consists  in  deep  manipulation  of 
the  tissues  beneath  the  mandible  and  the  sternomastoid  muscle. 
Nearly  every  patient  requires  this  treatment.  Glands  may  enlarge  be- 
cause  of  inflammation,  injury,  new  growth,  bacterial  invasion,  can- 
cer,  secondary  syphilis,  disease  of  any  of  the  tissues  drained  or  regurgi- 
tation, causing  pressure  on  important  nerves,  arteries,  veins,  etc. 

There  are  eight  tonsils:  The  two  faucial  or  palatine  tonsils,  to 
which  the  word  tonsils  is  frequently  limited,  though  strictly  it  should 
include  also  the  lingual  tonsils,  at  the  base  of  the  tongue,  (described  in 
Gray  under  tongue),  the  adenoid  or  pharyngeal  tonsils  on  the  upper  part 
of  the  posterolateral  walls  behind  the  fossae  of  RosenmuUer  and  the 
tubal  tonsils  surrounding  the  Eustachian  orifices. 

Osteopathy  for  School  Children 

Ear,  nose  and  throat  affections  would  rarely  occur  if  the  colds  and 
diseases  of  childhood  and  adolescence  were  properly  looked  after  in  the 
beginning.  Osteopathy  gets  astounding  results  in  these  cases  even 
when  of  long-standing.  In  nearly  all  cases  when  osteopathic  treatment 
is  given  before  great  structural  changes  have  taken  place,  the  child  is 
restored  to  a  practically  normal  condition,  is  mentally  and  physically 
efficient,  and  is  saved  years  of  discomfort. 

Children  should  not  be  sick.  And  they  would  not  be  sick  if  their 
noses,  throats  and  mouths  were  kept  normal,  and  due  attention  given 
to  diet  and  hygiene.  All  infectious  diseases  are  propagated  via  the 
nasal,  oral  and  pharyngeal  secretions.  Therefore,  (1)  No  child  with 
"running  nose"  should  be  allowed  to  play  with  other  children,  because 
the  nasal  discharge  may  be  charged  with  virulent  disease;  and  (2)  Any 
child  with  nasal  discharge,  hoarseness,  or  other  symptoms  of  sore  throat 
should  receive  expert  attention  at  once.  A  child  can  readily  be  trained 
to  do  its  breathing  exercises,  take  the  nasal  douche  and  gargle  the  throat, 
by  simply  making  sport  of  it  as  if  it  were  a  game.  Care  must  be  taken 
not  to  frighten  the  child. 

Normal  and  Abnormal  Adenoid  Tissue 

With  the  anatomy  of  the  pharynx  well  in  mind  we  will  briefly  re- 
view the  function  of  the  lymphoid  tissue  forming  the    tonsillar  ring. 


In  Health  and  Disease  237 

Formed  by  a  special  development  of  the  mucous  membrane,  and  char- 
acterized by  an  infolding  of  the  epithelium  into  pockets  or  crypts,  this 
tissue  has  engaged  the  attention  of  many  investigators  without  definite 
determination  of  its  exact  function.  However,  we  know  that  it  is  al- 
ways there  normally,  and  presumably  it  is  there  for  a  good  purpose. 
Other  vital  organs  whose  function  is  not  definitely  known  are  the  spleen, 
thyroid,  thymus,  pituitary  and  adrenal  glands.  These  adenoid  or  ton- 
sillar  masses  do  not  look  like  remnants  of  ancestral  organs,  such  as  the 
appendix,  which  is  also  rich  in  lymphoid  tissue. 

They  probably  have  a  function  during  childhood  in  som*^  way  simi- 
lar to  the  thymus  gland,  which  atrophies  after  a  few  years  as  do  the 
tonsils.  From  their  location  and  structure,  I  believe  it  is  safe  to  assume 
that  in  infancy  and  childhood  this  tissue  helps  to  warm,  moisten  and 
clean  the  inspired  air,  catching  and  holding  the  microorganisms  in- 
haled. The  nose  and  mouth  are  the  only  open  portals  through  which 
disease  germs  may  enter  easily.  Surrounding  these  open  passages  we 
find  the  adenoid  or  tonsillar  tissue  standing  ready  to  receive  these  germs 
into  its  crypts,  holding  them  there  and  not  allowing  them  to  penetrate 
any  farther.  The  presence  of  a  disease  germ  stimulates  phagocytosis 
and  other  auto-protective  reactions  enabling  the  body  to  make  an  anti- 
dote for  that  disease.  The  tonsil  may  either  secrete  an  antitoxin,  or 
permit  the  necessary  phagocytic  action  to  render  the  microorganisms 
inactive.  Or  it  may  in  some  undetermined  manner  use  the  disease 
germs  to  elaborate  serums  or  antibodies  to  protect  the  individual  from 
the  germs  that  surround  it,  particularly  those  to  which  children  are 
susceptible. 

Normal  Tonsils  Closely  Related  to  Immunity 

If  this  hypothesis  should  prove  to  be  true  or  partly  true;  it  would 
follow  that  the  adenoid  or  tonsillar  tissue  is  the  natural  protection  of 
the  body  against  the  exanthematous  fevers  and  other  infections.  There- 
fore, a  child  with  a  pharynx  normal  in  structure  and  function  would  be 
immune  to  the  common  diseases  of  childhood.  Hence,  the  tonsils  and 
adenoids,  when  doing  no  harm,  should  be  let  alone. 

It  is  fair  to  assume  that  the  adenoid  or  pharyngeal  tonsil  is  a  most 
important  organ  of  defense  against  bacterial  invasion.  It  produces 
phagocytes  which  attack  and  ingest  the  bacteria  which  gain  entrance 
through  the  nose.  Long-continued  phagocji;osis  produces  chronic  hy- 
pertrophj'  of  adenoid  tissue  in  response  to  functional  demand.  To 
remove  the  adenoid  while  thus  engaged  in  killing  bacteria,  is  to  lay  the 
body  open  to  bacterial  invasion.    When  the  blood  and  nerve  supply 


238  Lymphatics 

and  drainage  both  venous  and  lymphatic,  to  nose,  sinuses  and  pharynx 
are  normal,  the  adenoid  tonsil  is  not  overtaxed  and  does  not  hypertrophy. 
The  logical  cure  for  adenoids  is  to  correct  the  lesions  and  other  condi- 
tions which  permit  too  many  bacteria  to  reach  the  adenoid.  Merely 
taking  out  the  adenoid  tonsils,  does  not  remove  the  cause  of  the  hyper- 
trophy. As  a  result  of  removal  the  body  is  laid  open  to  invasion  and 
in  its  struggle  to  protect  itself  goes  right  on  building  up  adenoid  tissue 
and  in  a  very  short  while  has  it  back  where  it  was  before  operation.  The 
adenoid  tonsil  is  particularly  connected  with  the  prevention  of  cere- 
brospinal meningitis.  When  it  fails  in  this  task,  the  microorganisms 
overcome  the  phagocytes  on  the  pharyngeal  tonsil,  and  then  pass  along 
the  blood  vessels  and  lymph  vessels  and  involve  the  sphenoidal  sinus 
and  sella  turcica,  thence  spreading  to  the  meninges. 

Any  interference  with  nasal  space,  such  as  deviated  septum,  polypi, 
hypertrophied  turbinates,  etc.,  affects  nasal  respiration,  which  in  turn 
affects  the  nasopharynx  and  the  respiratory  tract.  When  nose-breath- 
ing is  prevented  or  reduced  by  obstruction,  the  nose  does  not  do  its  share 
of  bactericidal  work,  overtaxing  the  pharyngeal  tonsils.  Furthermore, 
since  the  child  now  breathes  through  its  mouth,  the  faucial  tonsils  also 
receive  more  bacteria  than  they  should  and  they  too  enlarge  in  response 
to  the  functional  demand.  In  a  number  of  cases,  I  have  noticed  that 
after  intranasal  technique  in  adults  to  correct  nasal  obstructions  there 
occurred  a  marked  atrophy  of  the  previously  enlarged  tonsils. 

Normally,  a  large  number  of  tonsillar  masses  are  found  imbedded 
in  the  mucous  membrane  of  the  side  and  back  of  the  pharynx.  They 
range  from  the  size  of  a  pinhead  to  a  small  pea.  The  true  adenoid  or 
pharyngeal  tonsil  is  present  at  birth  and  increases  in  size  with  the  growth 
jf  the  child  up  to  the  seventh  year.  It  remains  at  that  size  for  a  few  years 
and  then  diminishes,  is  quite  small  at  fifteen,  and  has  almost  disappeared 
by  twenty. 

Always  remember  this:  that  adenoid  tissue  in  the  posterior 

PART  OF  THE  PHARYNX  IS  NORMAL  IN  CHILDHOOD  AND  SHOULD  NOT  OB- 
STRUCT    BREATHING    NOR   OTHERWISE    DISTURB   THE    BODY. 

When  to  Suspect  "Adenoids** 

"Adenoids"  were  discovered  about  thirty  years  ago  in  Denmark 
and  the  operation  for  their  removal  then  began.  When  removed  they 
grow  again.  The  term  "adenoids"  or  "adenoid  vegetations"  means 
in  a  child  that  the  pharyngeal  tonsil  is  larger  than  normal  or  has  grown 
in  such  a  way  as  to  obstruct  breathing.  In  an  adult  it  means  that  the 
lymphoid  tissue  of  the  nasopharynx  has  not  properly  atrophied. 


In  Health  and  Disease  239 

In  most  cases  of  adenoids,  breathing  is  obstructed  because  the 
pharyngeal  tonsil  has  grown  so  large  that  it  takes  up  too  much  room  in 
the  nasopharynx  and  blocks  the  airway.  In  any  case  where  a  child 
does  not  breathe  easily  through  the  nose,  suspect  adenoids  unless  breath- 
ing  becomes  normal  in  a  few  days.  In  many  cases  the  child  can  breathe 
through  the  nose  when  awake;  but  at  night,  when  the  soft  palate  is  re- 
laxed, the  child  breathes  through  the  mouth.  If  the  obstruction  is  great- 
er,  the  child  has  to  breathe  through  the  mouth  at  all  times. 

The  ventilation  of  the  middle  ear  via  the  Eustachian  tube  maj-^  be 
interfered  with  by  adenoids  causing  periodical  or  persistent  deafness. 
Persistent  snoring  at  nights  in  children  is  often  due  to  adenoids. 

Examination  of  nasopharynx  may  be  made  by  palpation  or  by 
laryngoscopic  mirror  and  nasopharyngoscope.  In  digital  examination 
the  index  finger  (with  nail  filed  down  to  cushion)  is  passed  above  the 
soft  palate,  and  the  mass  of  adenoids  on  the  roof,  posterior  and  lateral 
walls  of  the  nasopharynx  are  felt  through  the  tip,  sides  and  nail  of  the 
finger. 

If  the  pharyngeal  tonsil  is  normal,  it  is  not  to  be  disturbed.  When 
its  drainage  is  interfered  with,  it  may  become  diseased;  when  it  is  over- 
taxed and  its  blood  supply  is  increased  it  hypertrophies.  When  it  hyper- 
trophies, it  reduces  the  airway  through  the  nasopharynx,  and  it  may  be- 
come a  serious  obstruction. 

All  obstructions  to  the  free  passage  of  air  through  the  nose  and 
nasopharj^nx  must  be  removed  and  the  airway  restored  to  normal  free- 
dom. Because  of  the  obstruction  to  breathing,  adenoids  produce  far- 
reaching  bad  effects  on  the  body,  the  reduction  of  oxygen  intake  result- 
ing in  loss  of  energy,  both  physical  and  mental,  with  consequent  retarded 
development.  Locally,  the  obstruction  results  in  mouth-breathing, 
arrested  development  of  the  nasal  cavities,  hypertrophy  of  tonsils,  irri 
tation  of  the  whole  respiratory  tract,  because  the  air  reaches  it  uncleaned, 
unwarmed,  unmoistened. 

The  condition  is  due  primarily  to  vasoconstrictor  paralysis  or  vagus 
autonomic  hj^peractivity,  resulting  from  osteopathic  lesions,  errors  of 
diet,  or  other  injurious  habits  or  environment.  Correction  of  lesions, 
nasal  breathing,  and  normal  diet  and  hygiene,  potentially  restore  nor- 
mality, and  in  cases  seen  before  the  breathway  is  much  obstructed,  may 
clear  up  the  symptoms.  Usually,  the  condition  passes  unnoticed  by 
the  parents  till  the  breathway  is  seriously  obstructed.  The  only  thing 
to  do  at  this  stage  of  the  condition  is  to  have  the  adenoids  removed  if 
they  obstruct  the  breathway.  The  operation  is  usually  neither  danger- 
ous  nor  difficult.     Up  to  the  age  of  five,  they  can  usually  be  removed  in 


240  Lymphatics 

one  treatment.  From  five  to  eight  or  ten,  they  can  be  removed  bj'^  five 
or  six  treatments.  After  ten  years  of  age  the  growth  of  fibrous  tissue 
makes  them  too  hard  to  remove  digitally  and  they  should  be  cleaned  out 
with  a  curette.  The  symptoms  of  adenoids  and  technique  of  the  treat- 
ment are  as  follows : 

Symptoms  of  Adenoids 

1 .  Catch  cold  easily. 

2.  Recurring  earache. 

3.  Nose  bleed. 

4.  Enuresis,  (wets  bed  at  night) 

5.  Restless  and  nervous. 

6.  Tires  easily. 

7.  Mouth  breathing. 

8.  Poor  appetite. 

9.  Constipation. 

10.     Chronic  nasal  discharge  from  both  nostrils. 
Examine  pharynx  digitally  under  anaesthesia  to  know  if  adenoids 
are  obstructing  the  airway  or  interfering  with  the  potency  of  the  Eus- 
tachian tube.     If  so,  remove  as  follows: 

Operation  for  Removal  of  Adenoids 

General  anaesthesia. 

Use  index  finger:  take  all  aseptic  precautions  as  indicated  in  post- 
nasal technique ;  file  index  finger-nail  down  to  cushion.  This  is  done  by 
first  making  a  knife-edge  on  nail  as  close  as  possible  to  cushion,  moving 
the  file  away  from  you  aftei-ward  filing  off  the  sharpness  level  with  cush- 
ion and  being  careful  to  file  off  all  corners  and  sharp  points  so  that  nail 
cannot  tear  the  delicate  mucous  membrane  of  the  pharynx. 

Insert  finger  in  pharynx,  entering  at  side  of  uvula.  Then  crush 
adenoids  with  back  of  fingernail  and  remove  shreds  as  much  as  possible. 
A  dull  curette  may  be  used  for  this  purpose.  Head  should  be  held  so 
that  nasopharynx  is  lower  than  larynx,  to  prevent  blood  from  entering 
larynx.  If  bleeding  does  not  stop  at  once,  it  may  be  controlled  by  suffi- 
cient pressure  upon  the  denuded  surface.  For  this  purpose,  a  long, 
curved  hemostat  holding  a  piece  of  picked  gauze  may  be  introduced  and 
pressed  against  the  bleeding  surface.  It  may  be  removed  in  three  or 
four  minutes.  Patient  should  rest  for  twenty-four  hours,  and  be  placed 
on  a  light,  bland,  unstimulating  diet  for  two  days,  gradually  returning 
to  normal  diet. 

Adenoids  are  often  a  sequala  of  acute  exanthemata.  The  irritation 
of  the  nasal  and  nasopharyngeal  mucous  membrane  and  the  increased 


In  Health  and  Disease  241 

numbers  of  bacteria  cause  overgrowth  of  the  lymphoid  tissue.  Much  of 
this  irritation  is  allayed  by  osteopathic  treatment  of  these  conditions 
as  indicated.  I  believe  that  adenoids  will  not  occur  following  these  dis- 
eases if  proper  osteopathic  treatment  is  given  as  outlined.  The  human 
race  could  be  emancipated  from  most  diseases  if  the  nose  and  naso- 
pharynx could  be  kept  normal.  Moreover,  I  believe  that  children  re- 
ceiving regular  osteopathic  treatment  will  not  easily  contract  any  more 
"  children's  diseases. " 

Another  serious  element  of  danger  from  adenoids  is  that  they  invade 
the  fossa  of  RosenmuUer  and  even  extend  to  the  tubal  tonsil  and  block 
the  Eustachian  tube.  In  both  these  respects  they  interfere  with  the 
ventilation  of  the  middle  ear.  Many  cases  of  middle  ear  deafness  have 
more  or  less  adenoid  overgrowth,  which  should  be  removed  and  normal 
blood  supply  and  drainage  re-established.  The  whole  problem  of  ade- 
noids, tonsils,  etc.  is  well  covered  in  Ballenger.  Study  it  well  there. 
But  do  so  in  the  light  of  your  own  osteopathic  viewpoint.  The  adeno- 
tome,  curette,  forceps,  etc.  are  well-illustrated  and  explained. 

Remember,  that  from  the  osteopathic  viewpoint,  the  adenoids  are 
overgrown  glands,  mostly  lymphatic.  When  normal  they  have  an  im- 
portant function  to  perform.  When  abnormal  they  are  probably  un- 
able to  perform  their  function  normally.  The  whole  trouble  may  clear 
up  when  you  normalize  the  nasal  ventilation,  the  venous  and  lymphatic 
drainage  and  correct  the  lesions  found,  cervical  and  upper  dorsal;  if  it 
does  not  clear  up  within  a  few  weeks,  the  indications  are  to  remove  the 
adenoids  and  keep  up  the  treatment  to  restore  the  nasopharynx  to 
normal.  Simply  removing  adenoids  without  osteopathic  treatment 
as  indicated,  is  useless,  for  the  tissue  grows  right  back  again,  as  long  as 
the  ventilation,  blood  supply  and  drainage  remain  abnormal. 

The  Lingual  Tonsils 

The  Ungual  tonsils,  situated  together,  at  the  base  of  the  tongue, 
cause  many  coughs.  Manipulation  of  lingual  tonsil,  with  index  and 
middle  finger  at  the  base  of  the  tongue  gives  relief  and  is  diagnostic. 
If  permanent  relief  is  not  afforded  by  deep  local  manipulation  and  drain- 
age of  lymphatics  and  restoration  of  the  blood  and  nerve  supply  by  cor- 
recting lesions  found,  then  lingual  tonsil  should  be  removed  surgically. 
The  lingual  tonsil  sometimes  overlaps  and  blends  with  the  faucial  ton- 
sil. The  lingual  tonsil  atrophies  at  fourteen  years  of  age,  after  which 
the  base  of  the  tongue  becomes  carpeted  over  with  adenoid  follicles. 


242  L-iTVIPHATICS 

The  Faucial  Tonsils 

The  faucial  tonsils  are  situated  on  both  sides  of  throat  in  the  pocket 
between  the  anterior  and  posterior  pillars  of  the  fauces. 

One  thing,  bear  in  mind:  a  tonsil  which  sticks  out  into  the  throat 
may  look  large  and  still  be  no  larger  than  is  normal  for  a  person  of  that 
age  and  it  is  no  more  hkely  to  do  harm  than  is  one  out  of  sight.  Size 
has  no  great  importance.  Are  they  healthy  or  not,  is  the  important 
factor.  How  many  physicians  who  examine  our  school  children  daily 
in  our  public  schools  know  this?  Tonsils  that  are  unhealthy  often  show 
repeated  attacks  of  tonsillitis. 

Quinsy  is  a  peritonsillar  abscess  or  a  collection  of  pus  in  the  region 
just  behind  the  capsule  of  the  tonsil. 

The  removal  of  tonsils  has  been  done  more  or  less  for  a  century. 
The  operation  appears  to  become  popular  at  times  and  then  go  out  of 
fashion.     It  is  now  more  frequent  than  ever  before. 

The  lymphatics  draining  the  tonsil  empty  into  the  deep  cervical 
chain  beneath  the  sternomastoid  muscle.  The  lymph  nodes  that  re- 
ceive the  tonsillar  efferent  lymphatics  are  situated  near  the  tip  of  the 
great  cornu  of  the  hyoid  bone  overlapping  the  jugular  vein.  They 
are  almost  invariably  enlarged  in  tonsillar  affections,  and  this  enlarged 
mass  is  often  mistaken  for  the  tonsil.  The  tonsil,  however,  corresponds 
to  the  angle  of  the  jaw.  The  swelling  of  these  glands  in  scarlet  fever  has 
led  some  investigators  to  believe  that  scarlet  fever  finds  its  way  into  the 
system  through  the  faucial  tonsils.  These  glands  are  also  frequently  the 
first  to  enlarge  in  tuberculous  disease  of  the  cervical  glands,  hence  the 
tonsils  may  be  the  primary  source  of  infection  for  tuberculosis.  The 
tonsils  are  usually  inflamed  at  the  onset  of  rheumatic  fever.  Many 
other  conditions  also  point  to  the  faucial  tonsil  as  the  site  of  entry  of 
virulent  disease;  and. as  a  strong  protection  against  disease  when  normal. 

The  tonsillar  crypts  or  fossulae,  formerly  called  follicles,  are  tubular 
recesses  or  pockets  in  the  tonsil  (the  faucial  tonsil  has  about  20),  lined 
with  stratified  pavement  epithelium.  They  are  surrounded  by  follicular 
tissue  and  extend  right  through  the  follicular  tissue  to  the  capsule.  They 
may  become  filled  with  food,  dead  epithelimn,  bacteria,  leucocytes  and 
mucus,  causing  local  congestion  and  (perhaps)  constitutional  disturb- 
ance.  When  for  any  reason  the  crypts  are  clogged,  or  the  nerve  and 
blood  supply  to  the  tonsil,  or  the  venous  or  lymphatic  drainage  from  it, 
are  interfered  with,  the  tonsil  may  become  the  seat  of  inflammation. 
The  tonsil  has  been  held  responsible  for  rheumatism,  endocarditis,  in- 
sanity, and  what  not.     Streptococci  lodged  in  the  tonsil  are  supposed 


In  Health  and  Disease  243 

to  be  the  active  agent.  The  toxins  reach  the  blood-stream  directly  or 
by  way  of  the  lymphatics.  The  toxins  are  supposed  to  cause  insanity 
by  reaching  the  brain  via  the  sheath  of  the  third  division  of  the  fifth 
cranial  nerve  which  is  in  relation  to  the  tonsil.  While  the  tonsil  is  not 
universally  accepted  as  the  cause  of  these  conditions,  it  is  well  to  bear 
this  possibility  in  mind  and  consider  the  tonsil  whenever  such  a  case 
presents  itself.  The  crj'pts  may  also  harbor  acute  infections,  which 
may  therefore  be  transmitted  to  other  people. 

The  decomposition  of  retained  epithelial  structures  within  these 
crj^pts  produces  the  fetid  breath  found  in  some  cases  of  enlarged  tonsil, 
and  probably  plays  a  part  in  reducing  the  vitality  of  the  tonsil  and  caus- 
ing tonsillitis.  When  calculi  form  in  the  crypts  they  irritate  twigs  of 
the  glossopharyngeal  nerve  and  cause  a  spasmodic  cough. 

While  Metchnikoflf  has  shown  that  mucus  taken  from  the  surface 
of  the  tonsil,  is  rich  in  leucocytes  and  phagocytes  filled  with  microor- 
ganisms, still  the  tonsil  differs  from  lymphatic  glands  in  its  construction 
and  in  the  possession  of  the  fossulae  or  crypts.  There  are  no  lymphatic 
sinuses  around  the  tonsil.  W^hen  normal,  the  tonsils  do  not  absorb 
liquid  or  solid  particles  from  the  oral  cavity.  The  lateral,  or  external 
deep  surface  of  the  faucial  tonsil  is  encased  in  a  firmly  adherent,  strong, 
fibrous  capsule,  into  which  are  inserted  muscular  fibres  derived  from  the 
superior  constrictor  of  the  pharynx.  The  sheath  is  not  perforated  by 
lymphatics,  nerves,  arteries  or  veins.  It  is  firm  and  solid  and  prevents 
abscesses  of  the  tonsil  from  opening  into  the  maxillopharyngeal  space. 
The  sheath  sometimes  sends  a  network  of  fibrous  tissue  into  and  be- 
tween the  folds  of  the  mucous  membrane  and  along  the  blood  vessels 
of  the  tonsil  which  prevents  the  blood  vessels  from  readily  contracting 
when  cut.  The  severe  hemorrhage  thus  produced  is  often  wrongly  at- 
tributed to  hemophilia.  HemophiUacs  may  be  detected  before  opera- 
tion by  letting  a  few  drops  of  blood  and  testing  for  clotting  by  passing 
needle  through  them.  The  tonsil  is  only  slightly  vascular.  Its  nerve 
suppb'  is  not  clearly  established.  The  production  of  lymphocytes  within 
the  follicles  has  been  observed.  These  lymphocytes  pass  through  the 
mucous  membrane  into  the  cr>'pts  and  thence  to  the  mouth  where  they 
are  thought  to  be  identical  with  the  corpuscles  of  the  saliva. 

It  is  difficult  to  define  a  normal  tonsil.  The  size,  shape,  consistency, 
color,  weight  and  general  appearance  vary  in  different  individuals,  and 
from  time  to  time  in  the  same  individual.  These  characteristics  under- 
go  constant  change  from  infancy  to  old  age.  The  faucial  tonsils  are 
largest  from  three  to  .eighteen  yeai-s,  after  which  they  diminish  in  size, 
have  a  smooth  surface  and  a  firm,  cartilaginous  consistency.     Although 


244  Lymphatics 

often  large  enough  to  annoy  during  childhood,  they  generally  cease  to 
annoy  after  puberty.  With  advancing  years  the  tonsil  atrophies,  gets 
harder  and  smaller  and  infections  become  less. 

The  Tonsil  Has  a  Wide  Range  of  Motion  and  Is  not  Fir  mly  Bound 
Down  to  the  Sinus  Tonsillaris 

The  tonsil  is  loosely  adherent  to  the  sinus  tonsillaris  which  is  a 
pyramidal  space  bounded  by  the  anterior  faucial  pillar,  the  posterior 
faucial  pillar,  and  the  superior  constrictor  of  the  pharynx.  The  tonsil 
is  moved  inward  by  the  superior  constrictor  muscle  in  swallowing,  and 
outward  by  the  stylopharyngeus.  The  anterior  pillar  may  be  well- 
developed  or  poorly-developed.  The  tonsil  thus  presents  very  different 
appearances  within  a  few  seconds,  and  the  extent  to  which  it  projects 
beyond  the  level  of  the  pillars  gives  no  true  idea  of  its  size.  Above  the 
tonsil,  is  the  tonsillar  recess,  where  the  pillars  meet  the  soft  palate,  and 
joining  the  pillars  above  is  the  plica  supratonsillaris.  Below,  the  plica 
tonsillaris  passes  from  the  anterior  pillar  to  end  on  the  antero-inferior 
aspect  of  tonsil.  The  plica  is  composed  of  a  fold  of  the  mucous  mem- 
brane. 

The  plica  protects  the  tonsil  during  deglutition  and  prevents  food 
from  entering  the  crypts.  Under  certain  conditions  the  plica  becomes 
atonic,  allowing  food  to  enter  the  crypts  and  set  up  inflammation.  If 
the  plica  then  becomes  adherent  to  the  mucous  membrane  of  the  tonsil 
so  that  the  crypts  cannot  empty,  the  crypts  become  packed  with  (1)  the 
retained  food  particles;  (2)  desquamated  epithelial  cells  from  the  lining 
mucous  membrane;  (3)  the  leucocytes  that  are  continually  being  pro- 
duced; (4)  the  mucous  secretion  of  the  lining  mucous  membrane  of  the 
crypt;  and  (5)  bacteria.  In  some  cases  there  is  no  inflammation,  but 
in  many  cases  the  clogging  of  the  crypts  leads  to  inflammation,  reduced 
vitality  and  disease  of  the  tonsil.  To  relieve  this  obstruction  some 
operators  are  advocating  a  resection  of  the  plica  triangularis,  but  we 
osteopaths  contend  that  it  is  normal  to  every  throat  and  has  an  important 
protective  function  and  should  be  freed  but  not  removed. 

Tonsils,  cHnically,  may  be  divided  into  free  and  submerged,  and 
may  be  large  or  small,  fibrous,  hypertrophied,  atrophied,  infected,  etc. 

Free  tonsils  have  very  little  plica,  and  when  large,  extend  promi- 
nently beyond  the  faucial  pillars.  The  surface  is  studded  with  crypts. 
Submerged  tonsils  have  a  well -developed  plica  and  may  be  either  small 
or  large.  Even  when  large  they  do  not  have  a  cryptic  appearance  over 
the  entire  phaiyngeal  aspect. 


In  Health  and  Disease  245 

Tonsillectomy  May  be  Avoided  by  Freeing  the  Plica  and  Draining 

the  Crypts 

In  some  cases  the  plica  may  be  freed  from  the  tonsil  by  simply  sepa- 
rating it  with  the  index  finger.  This  technique  saves  the  tonsils  and 
avoids  tonsillectomy  in  90%  of  the  cases  among  children  and  75%  of 
adult  cases.  Dr.  James  D.  Edwards  of  St.  Louis,  in  May,  1915,  in  an 
article  in  the  A.  O.  A.  Journal  on  "Conservative  Surgery  of  the  Tonsil" 
advocated  circumcision  of  the  tonsil,  by  separating  the  pillars  and  loos- 
ening up  the  plica  with  the  index  finger.  This  was  followed  by  Dr. 
Murphy,  an  allopath  of  Mason  City,  Iowa,  who  advocated  the  same 
technique  several  months  later,  using  blunt  scissors  to  dissect  the  ad- 
hesions between  the  pillars  and  tonsils.  Osteopathy  claims  priority  for 
this  technique.  Dr.  Edwards  uses  general  anaesthesia  and  does  the 
work  in  one  treatment.  General  anaesthesia  is  essential  in  children, 
but  in  adults  it  may  also  be  done  under  local  anaesthesia,  the  tonsils  and 
pillars  being  desensitized  with  procain. 

When  the  plica  is  not  adherent  to  the  mucous  membrane  of  the 
tonsil,  or  after  it  is  freed  as  above,  the  retained  material  may  be  with- 
drawn either  by  suction,  or  by  pressure  from  behind.  Dr.  T.  J.  Ruddy 
of  Los  Angeles,  uses  a  "Ruddy  Tonsil  Suction  Cup"  producing  suction 
by  means  of  a  "Bulb."  This  aspirates  the  retained  material  from  the 
crypts.  It  is  excellent  technique  to  diagnose  diseased  tonsils,  as  the  pus 
can  be  collected  with  ease  for  microscopic  examination.  This  instru- 
ment can  be  purchased  from  Sharp  and  Smith,  Chicago. 

Dr.  Edwards  uses  an  instrument  called  "Edwards  Tonsil  Searcher" 
to  explore  the  plica,  crypts  and  tonsillar  recess  and  to  press  the  material 
from  the  ciypts.  It  is  a  blunt  probe  bent  at  a  right  angle  and  with  it 
the  anterior  pillar  of  the  fauces  is  pressed  backward  and  outward,  caus- 
ing the  tonsil  to  come  forward  into  the  throat.  This  technique  everts 
the  tonsil  and  exposes  the  crypts  and  hidden  pockets.  The  gagging 
of  the  patient  then  squeezes  or  milks  the  tonsil  so  that  the  crj^pts  are 
emptied  from  behind.  The  extruded  material  escapes  into  the  throat 
and  is  expectorated. 

The  tonsil  may  then  be  sprayed  with  normal  saline  solution,  and  if 
it  is  suspected  that  the  crypts  still  retain  material,  a  bent  trocar  may  be 
introduced  into  the  crypts  and  the  saline  solution  forced  directly  into 
them  by  a  syringe.  In  some  cases,  it  is  advisable  to  swab  out  the  crypts 
with  a  cotton  wound  applicator  dipped  in  iodine.  This  is  advisable  be- 
fore operation  to  help  make  the  field  of  operation  aseptic,  and  prevent 
possible  infection  that  may  arise  from  an  otherwise  unsuspected  tonsil. 


246  Lymphatics 

Ballenger  points  out  that  the  pricky  sensation  in  the  throat  accompanied 
by  slight  soreness  that  persists  for  several  days  is  due  in  some  cases  to 
infection  in  the  tonsil,  and  when  present  is  an  indication  to  use  caution, 
and  to  make  sure  that  the  crypts  are  rendered  aseptic  before  operation. 

Relation  of  Tonsils  to  Deafness 

The  tonsil  cannot  press  the  Eustachian  tube,  but  it  may  disturb  the 
soft  palate  and  the  tensor  palati  muscle  which  helps  keep  the  tube  patent. 
The  deafness  in  these  cases  is  however,  more  likely  due  to  adenoids  or  to 
hypertrophy  of  the  adenoid  tissue  within  the  mucous  membrane  of  the 
Eustachian  tube  itself,  or  to  extension  of  inflammation  from  the  inflamed 
tonsil.  Many  cases  of  deafness  in  which  the  tonsils  have  been  removed, 
have  not  cleared  up  for  a  considerable  time,  indicating  that  usually  the 
tube  is  not  blocked  by  any  mechanical  interference,  but  is  occluded  or 
rendered  less  patulous  by  the  same  hypertrophic  process  which  affected 
the  tonsil.  The  deafness  was  not  due  to  pressure  but  to  extension  of 
the  inflammatory  process.  Moreover,  that  inflammatory  process  is  due 
to  osteopathic  lesions  interfering  with  blood  and  nerve  supply  and  venous 
and  lymphatic  drainage;  and  when  these  are  corrected,  the  tonsil  and 
Eustachian  tube  soon  return  to  normal;  more  quickly  in  fact  than  they 
do  by  removing  the  tonsil.  And  when  once  returned  to  normal  they 
do  not  easily  become  diseased  again;  and  the  answer  to  the  argument 
that  they  are  no  use  in  and  might  just  as  well  be  out,  is  that  in  about  50% 
of  the  cases  in  which  they  are  removed,  one  or  other  of  the  important 
palatal  muscles  is  no  longer  able  to  work  properly.  When  the  tensor 
palati  is  affected,  the  Eustachian  tube  tends  to  become  more  occluded 
resulting  in  increased  deafness. 

Every  Inflamed  Tonsil  Should  be  Accurately  Diagnosed 
and  Adequately  Treated 

Follicular  Tonsillitis  (or  acute  fossulitis,  as  it  is  now  called)  may  be 
distinguished  from  diphtheria  by  laboratory  diagnosis  and  by  inspec- 
tion. The  Klebs-Loffler  bacillus  identifies  diphtheria.  It  is  not  found 
in  follicular  tonsillitis.  In  diphtheria  the  membrane  is  a  dirty  white 
color,  continuous,  sharply  defined,  and  leaves  a  raw  surface  when  torn 
off;  in  follicular  tonsillitis  it  is  yellow,  patchy,  tears  off  without  lacera- 
tion, not  continuous  and  has  irregular  sloping  edges,  and  an  exudate  on 
surface  of  tonsil.  Scarlet  fever  is  more  violent  in  onset  and  the  eruption 
comes  out  in  24  hours.  These  three  diseases  must  always  be  differen- 
tiated in  any  sore  throat,  and  all  precautions  taken.  They  occur  most 
frequently  in  children,  are  quite  acute,  sudden  in  onset,  and  have  tem- 
perature. 


In  Health  and  Disease  247 

Follicular  tonsillitis  is  accompanied  by  enlargement  of  the  tonsils 
making  swallowing  difficult.  Temperature  may  reach  103  or  104.  An- 
orexia, vomiting,  constipation,  pain  in  ear,  thorough  extension  along 
Eustachian  tube,  and  much  inflamed  throat.  Treatment:  Rest  in  bed, 
if  severe;  fever  diet,  wat^r  and  fruit  juices  for  three  days,  then  milk. 
General  spinal  treatment  to  promote  elimination.  Correct  lesions  in 
upper  cervical,  upper  dorsal  and  ribs,  etc.  Muscles  over  1st  and  2nd 
ribs  are  very  sore.  Digastric  is  contracted.  Relax  it.  Spring  jaw. 
Release  supra  and  infrahyoid  muscles.  In  younger  children  clean  out 
mouth  with  solution  one-third  liquor  antisepticus  U.  S.  P.,  or  listerine 
in  water. 

Coldpacks  around  throat  are  beneficial  unless  tonsil  contains  pus. 
In  suppurative  conditions  apply  heat.  Thoroughly  drain  the  lym- 
phatics, especialh'  around  angle  of  jaw,  as  described  in  Lecture  Thirteen. 
Sweep  the  tonsil  with  the  index  finger  and  manipulate  it  between  the 
index  finger  that  is  touching  it  within  the  mouth  and  the  other  index 
finger  that  is  outside  by  the  angle  of  the  jaw.  Stretch  the  soft  palate 
and  do  any  corrective  work  needed  in  the  nasopharynx,  clean  out  fossae 
of  Rosenmuller,  etc.  Treat  twice  or  three  times  daily  during  acute  ex- 
acerbations. During  chronic  inflammatory  periods  treat  daily  till 
drainage  is  established,  then  three  times  a  week.  Recurrent  tonsil- 
litis can  usually  be  controlled  in  one  day  by  one  general  treatment  to 
free  up  elimination  followed  by  enema,  etc.,  and  then  two  other  internal 
throat  treatments.  Order  gargle  of  Lugol's  solution,  10  drops  to  haK 
a  glass  of  water  everj^  two  hours.  Lugol's  solution  is  a  ''Compound 
Solution  of  Iodine. "  It  is  an  aqueous  solution  of  5%  of  iodine  and  10% 
of  potassium  iodide,  and  should  be  in  the  office  of  every  physician  who  is 
doing  nose  and  throat  work.  Irrigate  the  throat  with  about  two  quarts 
of  normal  saline  at  a  temperature  of  about  110,  twice  or  three  times  daily, 
and  irrigate  the  nose  with  same  quantity  of  normal  saline,  morning  and 
evening.  Give  osteopathy  a  fair  trial  and  the  case  will  nearly  always 
clear  up. 

After  attack  subsides,  with  history  of  recurrent  attacks,  consider 
tonsillectomy.  After  tonsillectomy,  post-operative  osteopathic  treat- 
ment should  be  kept  up  for  a  long  enough  period  to  restore  the  pharynx 
to  normal  condition,  otherwise  the  same  trouble  will  recur,  despite  the 
absence  of  the  tonsils.  The  condition  is  due  to  vasomotor  paralysis 
and  vagus  hyperirritability.  Therefore,  osteopathic  treatment  is  ab- 
solutely essential  to  restore  vascular  tone,  and  dietary  and  other  habits 
must  be  corrected  to  remove  irritation  of  vagus  and  sacral  autonomics. 
Reason  out  treatment  for  each  case  along  lines  laid  down  in  Haj'  Fever 


248  Lymphatics 

and  Asthma:  Each  case  is  different,  but  the  underlying  principles  apply 
to  all  cases  in  some  degree. 

In  acute  tonsillitis,  Edwards  swabs  tonsil  with  90%  of  silver  nitrate, 
being  careful  to  touch  the  swab  to  a  piece  of  gauze  before  applying  to 
the  tonsil  (to  avoid  dripping).  This  is  allowed  to  remain  three  min- 
utes  (it  blanches  the  tonsil)  and  is  followed  by  swabbing  the  tonsil  with 
saturated  solution  of  sodium  chloride,  (table  salt,  chemically  pure). 
This  neutralizes  the  caustic  action  of  the  silver  nitrate.  Usually  two 
applications  together  with  osteopathic  treatment  to  correct  lesions  and 
normalize  the  nose  and  throat,  will  cure  a  severe  case  of  acute  tonsillitis. 

Chronic  tonsillitis  is  a  chronic  inflammation  of  the  tonsils  and  other 
lymphoid  tissue  of  the  throat.  It  follows  repeated  attacks  of  acute  ton- 
sillitis. It  is  also  a  sequela  of  many  of  the  infectious  diseases.  The 
tonsils  are  permanently  enlarged,  but  may  be  either  free  or  submerged; 
are  rough  and  pitted.  There  is  some  difficulty  in  swallowing  and  breath- 
ing. The  child  becomes  a  mouth -breather,  dull  and  backward,  does  not 
develop  as  he  should,  and  sometimes  shows  Rickety-rosary  and  Har- 
rison's groove.  Absorbed  toxins  produce  headache,  etc.  The  cause 
of  the  trouble  is  often  overlooked  and  you  have  a  chance  to  make  a  spec- 
tacular cure  because  many  of  these  cases  clear  up  after  removal  of  the 
adenoids,  followed  by  correction  of  cervical  and  upper  dorsal  lesions  and 
thorough  osteopathic  treatment  till  restored  to  normal.  If  case  is  seen 
after  tonsil  is  fibrous,  have  it  out.  The  condition  will  recur  if  osteopathic 
treatment  is  not  given. 

When  to  Advise  Operation 

If  adenoids  are  really  obstructing  nasal  breathing,  it  is  best  to  re- 
move them,  because  their  removal  does  very  little  damage  compared  to 
the  serious  efi"f^cts  of  mouth -breathing.  But  if  the  symptoms  are  trivial, 
the  adenoids  and  tonsils  should  not  be  taken  out  merely  because  they 
look  large.  Neither  should  tonsils  be  taken  out  at  the  same  time  as  the 
adenoids  are,  just  to  have  it  over  in  one  operation.  Before  advising 
removal  of  tonsils,  one  should  be  absolutely  certain  that  the  disease 
that  affects  the  tonsil  cannot  be  cleared  up  by  osteopathy  or  some  other 
rational  treatment. 

The  abnormal  condition  of  the  tonsil  may  be  primary,  secondary, 
systemic,  reflex,  mechanical  or  hyperplastic.  If  primary,  it  starts  in 
the  mouth  and  affects  chiefly  the  crypts  (fossulae).  Use  Edwards' 
method  to  free  up  the  plica  and  pillars  of  the  fauces.  Open  the  crypts 
to  establish  free  drainage  from  the  crypts.  Correct  the  lesions  that 
affect  the  blood  and  nerve  supply  and  drainage.     And  squeeze  or  manipu- 


In  Health  and  Disease  249 

late  the  tonsil  between  a  finger  in  the  fauces  and  a  finger  beneath  the 
ramus  of  the  jaw. 

Secondary  affection  is  via  the  lymph  channels,  chiefly  from  the 
nose.  When  the  nose  and  sinuses  are  restored  to  normal  and  kept  clean 
the  tonsil  condition  will  clear  up  without  operation. 

Systemic  affection  of  the  tonsil  via  the  blood  is  quite  common,  and 
the  tonsil  is  not  to  be  removed  simply  because  attacked.  Rather,  the 
channels  of  elimination  should  be  stimulated  and  the  formation  of  anti- 
bodies in  the  spleen  increased,  so  that  the  general  bodily  condition  can 
be  thrown  off. 

Reflex  affection  of  the  tonsil  may  come  from  dental  caries,  gingivitis, 
pyorrhea,  or  other  irritants  to  the  fifth  cranial  nerve,  as  well  as  from 
spinal  lesions  and  rib  lesions  from  the  fourth  dorsal  up  to  the  occiput. 
Hyoid  and  thyroid  lesions  may  affect  the  drainage  via  the  deep  cervical 
lymphatics,  and  contractions  of  the  cervical  muscles  may  also  interfere. 

The  tonsil  may  be  enlarged  in  response  to  mechanical  stimuli  from 
the  faucial  pillars  and  the  constrictors  of  the  phaiynx  and  stylo-pharyn- 
geus,  also  from  misuse  of  the  voice.  Very  tight  biting  contracts  the 
pterygoids  and  forces  the  tonsils  toward  the  median  line  of  the  fauces 
against  the  bolus  of  food,  permitting  food  to  enter  the  crypts  with  greater 
force  than  the  delicate  structure  can  stand.  These  cases  should  be 
given  the  throat  exercises  as  in  Lecture  Sixteen  and  should  receive  voice 
training  in  singing  and  elocution. 

When  tonsils  are  hypertrophied  or  hyperplastic  or  diseased,  the 
trouble  is  nearly  always  the  effect  of  some  derangement  of  function  of 
some  other  part  of  the  body.  If  this  is  found  and  corrected,  the  tonsils 
will  become  healthy  again.  Do  not  opprate  unless  the  tonsils  are  a  men- 
ace to  health.  In  cases  where  you  have  definitely  determined  the  na- 
ture of  the  disease  of  the  tonsil  (placed  it  in  its  proper  group)  and  given 
it  consistent  osteopathic  treatment  without  results,  it  is  best  to  remove 
the  tonsils.  But  if  the  symptoms  are  trivial,  the  size  of  the  tonsils  is 
not  an  indication  for  removal.  If  the  nose  were  kept  clean,  few  opera- 
tions on  the  tonsils  would  be  necessary.  By  keeping  the  nose  and  mouth 
clean,  and  giving  thorough  osteopathic  treatment  to  normalize  all  the 
structures  related  to  the  tonsil,  we  can  save  nearly  all  tonsils.  Faulkner, 
in  his  book  "The  Tonsils  and  the  Voice,"  1913,  states  that  Frederic 
Young  found  all  prima  donnas  with  extraordinary  voices  had  big  tonsils. 
Also,  that  among  8,000  pupils  examined  by  Neustaedter,  tonsils  were 
largest  in  the  best  pupils,  and  the  best  singers  had  fifty  per  cent  more 
tonsils  than  the  poorest.  Finally,  competent  authorities  quoted  by 
Faulkner  differ  as  to  the  advisability,  or  even  the  possibility,  of  com- 


250  Lymphatics 

pletely  enucleating  or  removing  the  tonsil,  and  some  of  them  even  claim 
that  the  benefit  of  the  operation  is  in  proportion  to  the  amount  of  ton- 
sillar  tissue  which  remains  after  the  operation.  These  views  do  not 
seem  to  agree  with  current  practice.  In  view  of  all  the  anatomical, 
physiological  and  pathological  facts  and  probabilities,  I  think  it  is  best 
to  treat  all  tonsil  cases  without  operation  until  we  have  proof  that  the 
tonsil  in  a  given  case  is  an  actual  menace  to  the  health  of  the  individual. 
There  are  enough  tonsils  that  have  to  come  out  without  taking  out  ton- 
sils  that  can  be  saved. 

Improving  the  Drainage  From  tlie  Tonsil 

The  upper  part  of  the  tonsil  is  in  front  of  the  transverse  process 
of  the  atlas.  The  lateral  side  of  the  tonsil  is  in  relation  with  the  super- 
ior constrictor  muscle,  and  is  internal  to  the  angle  of  the  mandible.  It 
enlarges  in  the  line  of  least  resistance  toward  the  median  line  of  the 
pharynx,  with  but  little  effect  in  its  relations  laterally.  It  can  be  pal- 
pated in  the  normal  neck  by  placing  the  index  finger  as  close  to  the  front 
of  the  transverse  process  of  the  atlas  and  to  the  internal  surface  of  the 
mandible  as  possible.  Steady  drawing  forward  of  the  mandible  with 
the  index  finger  and  of  the  tissues  in  relation  to  it  with  the  middle  finger 
is  effective  in  draining  the  tonsil.  The  lymphatic  glands  near  the  tip 
of  the  greater  cornu  of  the  hyoid  receive  the  lymph  from  the  tonsils 
and  are  nearly  always  enlarged  if  the  tonsil  is  affected.  This  mass  is 
often  mistaken  for  the  tonsils.  The  glands  that  receive  the  drainage 
from  the  tongue  also  tend  to  enlarge  in  any  ear,  nose  or  throat  condi- 
tion. This  congestion  irritates  the  vagus  and  causes  decreased  heart 
action  and  general  systemic  depression.  This  depression  is  a  frequent 
symptom  in  ear,  nose  and  throat  conditions.  I  get  astonishing  relief 
from  the  congestion  and  the  consequent  depression  by  the  following 
technique.  Note  that  this  technique  is  given  after  I  have  first  freed  up 
the  kidney,  bowel  and  skin  elimination  by  such  treatment  as  is  indi- 
cated in  the  particular  case;  second,  established  normal  activity  of 
spleen,  pancreas,  liver,  stomach  and  intestines  by  appropriate  treat- 
ment; third,  thoroughly  relaxed  the  upper  dorsal  and  cervical  muscu- 
lature and  adjusted  the  vertebrae  so  as  to  insure  normal  secretory  and 
vasomotor  impulses  to  the  lymphatics,  veins  and  arteries  from  the  neck 
up;  and  fourth,  drained  the  Ijinphatics  beneath  the  sternomastoid. 
I  then  take  a  clean  towel  and  with  patient  on  back  have  patient  open 
mouth  wide  and  protrude  tongue,  I  grasp  the  tip  of  the  tongue  in  the 
towel  and  gently  but  firmly  squeeze  the  entire  tip  of  the  tongue  for 
about  an  inch  between  the  thumb  and  index  finger  of  both  hands.     This 


In  Health  and  Disease  251 

presses  the  lymph  against  the  lymph  nodes  and  irritates  them  to  activity. 
Then  draw  the  tongue  forward,  downward  and  lateralward  to  stretch 
the  tissues.  With  cotton  rolls  between  lips  and  teeth  to  avoid  cutting 
the  lips  on  teeth,  I  now  place  one  index  finger  in  the  mouth  between 
the  mandible  and  the  index  finger  of  the  other  hand  on  the  outside  be- 
tween the  mandible,  and  gently  manipulate  the  tissues  between  the 
fingers,  draining  them  toward  the  median  line.  Then  with  the  index 
finger  beneath  the  tongue  press  the  tongue  toward  the  opposite  side  of 
the  mouth,  and  with  the  outer  finger  reverse  the  motion.  These  move- 
ments thoroughly  stretch  and  drain  the  tissues  of  the  tongue  and  tonsil. 
Do  the  drainage  from  the  outside  only,  two  or  three  times  before  you  do 
any  inside  work  to  improve  drainage. 

Osteopathic  treatment  saves  practically  all  tonsils  except  those  that 
are  seriously  diseased.  Some  osteopathic  physicians  are  inclined  to 
claim  that  tonsillectomy  is  never  justified,  because  so  many  brilliant 
results  follow  osteopathic  treatment.  But  I  have  seen  a  number  of 
cases  of  large  fibrous  tonsils  and  seriously  diseased  tonsils,  the  removal 
of  which  was  decidedly  beneficial  to  the  patient.  Choose  the  least  evil 
in  such  cases.  It  is  bad  to  remove  tonsils,  but  in  cases  where  it  is  worse 
to  leave  them  in,  have  them  out.  In  children  they  are  rarely  diseased, 
and  normally  they  atrophy  at  puberty.  The  operation  is,  therefore,  in 
most  cases,  not  indicated  at  once.  There  is  no  hurry  about  operating 
and  there  is  nearly  always  time  enough  to  clear  up  the  condition  osteo- 
pathically,  because  these  structures  respond  promptly.  But  if  the  re- 
current tonsillitis  does  not  clear  up  under  osteopathic  treatment,  it  is 
best  to  remove  the  tonsils.  In  some  cases  they  are  enlarged  enough  to 
interfere  with  the  foodway,  making  swallowing  difficult;  or  they  may 
interfere  with  the  tensor  palati  and  indirectly  interfere  with  normal 
ventilation  of  the  middle  ear  through  the  Eustachian  tube.  Such  ton- 
sils obviously  are  better  out. 

The  normal  tonsil,  especially  during  the  first  twenty  years  of  life, 
is  a  useful  part  of  the  autoprotective  mechanism  of  the  body.  If  in  a 
given  case  it  is  found  to  be  diseased,  and  is  suspected  of  causing  symptoms 
of  infection  in  other  parts  of  the  body,  such  as  tuberculosis  of  the  cervi- 
cal glands,  osteomyelitis,  acute  articular  rheumatism,  endocarditis, 
nephritis,  orchitis,  adenitis,  laryngitis,  etc.,  and  if  it  fails  to  respond  to 
persistent  osteopathic  treatment  over  a  period  of  several  months;  the 
question  to  be  decided  is  then  whether  the  tonsil  has  become  so  diseased 
that  it  is  really  a  portal  of  infection  rather  than  a  barrier  and  defense. 
Since  in  these  cases  the  tonsil  is  not  performing  its  function  of  protec- 
tion, and  is  in  effect  a  menace  to  the  body,  it  should  be  completely  re- 


252  Lymphatics 

moved,  including  the  capsule.  If  any  part  of  the  tonsil  is  left,  it  wiL 
regenerate.  When  renioved,  the  tonsil  presents  the  appearance  of  a 
definite  mass  of  lymphoid  tissue  enveloped  in  a  smooth,  glistening  cap- 
sule on  its  outer,  lateral,  aspect,  and  mucous  membrane  on  its  inner, 
median,  aspect.  If  care  is  taken  to  avoid  injuring  the  muscles  in 
relation  to  the  tonsil,  there  is  very  little  hemorrhage  in  tonsillectomy. 
The  location  of  the  ascending  pharyngeal  artery,  of  the  pharyngeal 
venous  plexus,  and  of  the  main  arteries  whose  small  branches  supply 
the  tonsil  should  be  distinctly  borne  in  mind.  The  severe  bleeding  that 
occurs  in  some  tonsillectomies  is  due  to  rupture  of  one  or  more  of  these 
vessels.  I  have  seen  many  surgeons  remove  tonsils.  Some  of  them 
were  men  of  national  reputation.  But  never  in  my  life  have  I  seen  such 
rapid  and  efficient  tonsillectomies  as  those  performed  by  Dr.  Edwards 
at  the  1920  Convention  of  the  A.  O.  A.  at  Chicago.  In  case  after  case 
he  removed  diseased  tonsils  from  adults  in  the  phenomenal  time  of  four 
seconds  for  each  tonsil.  The  operation  was  practically  bloodless  and 
painless.  He  anaesthetizes  the  tonsil  by  swabbing  the  parts  with  10% 
cocaine  in  adrenalin  chloride  1-1000,  (48  grains  of  cocaine  to  1  ounce 
of  adrenalin  chloride).  Swab  every  three. minutes  for  ten  minutes.  He 
used  the  new  Sluder-Edwards  technique,  which  is  Edwards'  Finger 
Surgery  plus  Sluder  guillotine,  the  tonsil  being  digitally  dissected  from 
the  muscular  walls  of  the  sinus  tonsillaris  and  removed  completely  with 
the  capsule  intact,  without  damaging  the  muscles  of  the  faucial  pillars 
or  of  the  pharynx,  and  without  cutting  any  bloodvessels  except  the 
relatively  small  vessels  which  supply  the  tonsil  itself.  Edwards-Sluder 
technique  is  a  decided  improvement  over  the  operations  described  in 
Ballenger.  Dr.  Edwards  has  not  made  public  this  technique,  but  has 
given  me  the  privilege  of  telling  you  about  it  in  advance  of  publication. 

Tonsillar  and  Peritonsillar  Abscess 

Peritonsillitis  or  quinsy  is  an  inflammation  of  the  tissue  around 
the  tonsil  that  rapidly  becomes  an  acute  abscess,  calling  for  immediate 
draining  to  avoid  serious  complications  such  as  edema  of  the  larynx, 
strangulation,  or  ulceration  of  the  great  blood  vessels  in  the  neck.  For- 
tunately, it  is  rare  in  children,  l)eing  most  often  found  in  young  adults. 

Tonsillar  abscess  or  phlegmonous  tonsillitis  is  more  rare  than  quin- 
sy, the  upper  lobe  of  the  tonsil  being  most  usually  affected.  In  many 
of  these  cases,  if  free  drainage  is  restored  to  the  upper  lobe  the  condition 
may  be  aljorted.  Thoroughly  free  the  drainage  by  sweeping  out  the 
supratonsillar  fossa  with  the  index  finger.  (Nail  filed  down  to  cushion). 
Free  the  plica  and  clean  out  the  crypts.     If  this  does  not  stop  the  pro 


In  Health  and  Disease  253 

gress  of  the  inflammation,  slit  up  the  upper  part  of  the  tonsil,  or  lance  the 
tonsil  where  the  abscess  points  if  this  spot  can  be  found. 

In  quinsy  find  the  point  of  fluctuation  or  pointing  and  let  it  out. 
The  essential  thing  to  remember  is  that  the  pus  is  between  the  tonsil 
and  the  faucial  pillars  and  pharyngeal  constrictor,  but  not  in  the  tonsil. 
In  lancing  to  let  out  the  pus,  it  is  necessary  to  make  sure  that  the  peri- 
tonsillar space  is  drained;  if  this  precaution  is  not  taken  the  incision 
may  be  made  into  the  tonsil  without  allowing  the  pus  to  drain.  Oc- 
casionally the  pus  can  best  be  drained  by  making  an  incision  right  through 
the  tonsil  to  the  capsule. 

Fluctuation  is  usually  felt  in  the  upper  third  of  the  anterior  pillar. 
The  finger  feels  a  pumping  or  pulsating  sensation.  When  the  pus  is 
within  the  tonsil,  the  tonsil  is  swollen  (as  compared  with  its  fellow  of  the 
opposite  side)  and  extends  out  toward  the  median  line.  When  the  pus 
is  behind  the  capsule  of  the  tonsil,  the  tonsil  is  pushed  upward  and  may 
bulge  the  anterior  pillar.  It  has  a  certain  consistency  and  resistance  to 
the  touch,  whereas  the  place  to  lance  is  where  the  fluctuation  is  felt. 
Use  local  anaesthesia.  Make  the  incision  through  the  anterior  pillar,  far 
enough  anteriorly  to  avoid  incising  the  tonsil.  The  incision  should 
reach  behind  the  capsule  of  the  tonsil.  To  lance,  wrap  adhesive  tape 
around  lance  half  an  inch  from  the  point  and  then  make  an  incision  at 
the  place  where  the  abscess  points  if  this  spot  can  be  found.  Then  insert 
hemostat  and  by  spreading  it  enlarge  the  incision.  This  releases  the 
pus  in  nearly  all  cases.  If  the  pus  is  not  found,  it  may  be  pointing  pos- 
teriorly into  the  pharynx  and  may  discharge  into  the  larynx  causing 
death.  It  may  be  necessary  to  do  Ballenger's  operation  which  consists 
in  dissecting  the  capsule  away  from  the  superior  constrictor  muscle. 
It  is  also  sometimes  necessary  to  lance  the  posterior  pillar. 

Treatment  of  Pyorrhea 

Dental  caries  may  be  evident  on  inspection  of  the  teeth,  or  may  be 
hidden  by  the  adjoining  tooth.  Pus  cavities  may  be  located  on  the  roots 
of  teeth.  Pyorrhea  alveolaris,  also  called  suppurative  gingivitis  or 
Rigg's  disease,  is  characterized  by  a  purulent  discharge  from  between  the 
teeth  and  the  gums. 

There  is  a  septic  infection  of  the  sockets,  the  teeth  loosen,  and  the 
gums  are  eroded  and  recede.  These  symptoms  are  accompanied  by 
bleeding  gums,  foul  breath,  dyspepsia,  anaemia,  ill  health,  apathy,  ner- 
vous disturbances,  and  sometimes  general  pyemia,  synovitis,  and  arth- 
ritis, neurasthenia  and  depression.  Treatment  consists  in  keeping  the 
mouth  clean,  and  freeing  up  the  upper  dorsal  and  cervical  area  so  that 


254  Lymphatics 

a  normal  blood  and  nerve  supply  can  reach  the  sockets  of  the  teeth. 
Also  free  up  the  drainage  and  general  elimination,  and  stimulate  the 
spleen  to  the  formation  of  antibodies.  X-ray  the  teeth  and  have  pus- 
pockets  cleaned  out. 

Then,  locally,  press  the  gums  between  the  thumb  and  forefinger  and 
hold  for  a  few  seconds,  repeating  till  the  entire  upper  and  lower  gums 
have  been  treated.  Repeat  the  manipulation  of  the  cervical  deep  lym- 
phatics. Repeat  morning  and  evening,  until  tenderness  is  gone  and  blood 
supply  and  drainage  is  normal.  Try  this  technique  on  yourself  and  see 
whether  your  gums  are  normal. 

These  patients  should  have  three  tooth-brushes  and  use  a  different 
one  after  each  meal ;  allowing  it  to  dry  24  hours  before  using  again,  other- 
wise they  reinfect  their  gums  with  bacteria  remaining  on  the  damp  brush. 
A  dry  brush  has  very  few  bacteria  on  it. 

Edwards  described  the  following  technique  which  is  very  effective 
in  the  various  forms  of  laryngitis,  also  in  asthma  and  clergymen's  sore 
throat  and  voice  affections.  It  is  essentially  a  suspension  manipu- 
lation. This  is  done  by  passing  index  and  middle  finger  of  right  hand 
into  the  mouth,  on  the  dorsum  of  the  tongue  to  the  larynx.  The  index 
and  middle  finger  then  pick  up  the  right  and  left  cornua  of  the  hyoid, 
rocking  and  rotating  it,  while  the  left  hand  is  opposing  on  the  outside 
of  the  throat,  moving  the  thyroid  cartilage  in  the  opposite  direction. 
This  drains  the  saccule  and  ventricle,  releasing  the  passive  congestion 
and  the  muscular  and  ligamentous  contraction. 

Edema  of  the  Larynx 

In  this  form  the  inflammation  is  accompanied  by  exudation  and  in- 
filtration of  the  tissues,  as  distinguished  from  the  distinctly  catarrhal 
laryngitis,  or  the  spasmodic  nervous  laryngismus  stridulus.  Most 
usually  due  to  obstruction  to  the  internal  jugular  veins.  Also  due  to 
errors  in  diet,  such  as  too  much  salt,  or  too  large  a  proportion  of  irritat- 
ing substances,  that  overstimulate  the  kidneys,  and  irritate  the  vagus 
generally  throughout  the  digestive  apparatus  and  elsewhere.  The 
specific  lesion  must  be  corrected,  and  the  diet  and  other  habits  regulated. 
Thorough  elimination  must  be  secured  through  bowels,  kidneys,  skin 
and  lungs,  by  osteopathic  treatment,  enemata,  hot  bath  and  fresh  air. 
In  treating  thoroughly  relax  the  tissues  of  the  neck  and  throat,  raise  the 
clavicle,  and  relax  the  deep  anterior  muscles  and  tissues  of  the  root  of  the 
neck.  Drain  the  lymphatics.  Opening  the  mouth  against  resistance 
aids  the  circulation  of  the  carotids.  Treat  the  vagus  along  the  course 
of  the    sternomastoid    and  at  the  superior  cervical  region.     Treat  the 


In  Health  and  Disease  255 

superior  lan-ngeal  nerve  behind  the  superior  cornua  of  the  thyroid  car- 
tilage.  Treat  the  recurrent  laryngeal  nerve  at  the  inner  side  of  the 
sternomastoid  at  the  level  of  the  cricoid  cartilage.  Treat  deeply  along 
the  sides  of  the  larynx  and  trachea,  applying  the  fingers  close  along  the 
sides  of  the  trachea.  This  relieves  the  huskiness  and  spasm,  though 
the  spasm  often  depends  on  the  approximation  of  the  hyoid  to  the  thy- 
roid or  on  some  specific  osteopathic  lesion. 

Dropsy  from  kidney,  heart  or  lung  disease  must  be  treated  by  re- 
moving the  cause  of  the  primary  disease,  if  possible.  In  dangerous 
cases  of  edematous  laryngitis,  great  care  must  be  taken.  Intubation 
or  tracheotomy  may  become  necessary  to  prevent  suffocation,  but  ordi- 
narily an  operation  can  be  obviated  if  the  case  is  seen  in  time.  Hot 
footbaths,  hot  drinks,  milk  or  seltzer-water  may  give  relief.  The  con- 
dition and  operations  are  well  described  in  Ballenger.  It  is  well  to  read 
up  all  there  is  about  laryngitis  in  all  the  text -books  you  have  and  have 
your  treatment  definitely  in  mind,  because  when  you  are  called  into  any 
of  these  cases  it  is  usually  necessary  to  act  at  once. 

The  lymphatics  of  the  outer  ear  accompany  the  veins  and  empty 
into  the  posterior  auricular  and  parotid  lymph  glands.  These  in  turn 
drain  into  the  superior  deep  cervical  chain. 

Any  obstruction  to  venous  or  lymphatic  drainage  will  cause  a  pass- 
ive congestion  of  the  meatus  with  hypersecretion  of  cerumen. 

The  Lymphatic  Drainage  of  the  membrana  tympani  is  into  the 
parotid  and  posterior  auricular  lymph  glands  superficially,  and  into 
the  retropharyngeal  lymph  glands  via  the  lymphatics  along  the  Eus- 
tachian tube.  In  myringitis  or  any  other  diseased  condition  of  the 
membrana  tympani,  free  up  the  lymphatic  drainage  of  the  superior  and 
inferior  deep  cervical  chain,  then  the  parotid  and  posterior  lymph  glands, 
and  then  go  l^ehind  the  soft  palate,  clean  out  the  fossa  of  Rosenmuller 
and  drain  the  retropharyngeal  glands  by  two  or  three  strokes  of  the 
index  finger  in  the  upper  back  corner  of  the  pharynx  on  the  affected  side. 
If  this  is  done  early  enough,  and  the  lesions  corrected  and  other  sources  of 
irritation  cleared  up,  the  condition  will  improve  with  surprising  rapidity. 

Mucous  Membrane  of  the  Tympanum  or  Middle  Ear 

The  liiueous  membrane  of  the  middle  ear  is  continuous  with  that  of 
the  phar\'nx,  through  the  Eustachian  tube.  It  invests  the  ossicles, 
muscles  and  nerves  contained  in  the  tympanic  cavity;  forms  the  inner 
or  medial  layer  of  the  membrana  tympani,  and  the  lateral  or  outer  layer 
of  the  secondary  tympanic  membrane  that  closes  the  round  window. 
It  is  reflected  into  the  tympanic  antrum  and  mastoid  cells  which  it  lines 


256  Lymphatics 

throughout.  It  also  forms  several  vascular  folds  which  give  the  interior 
of  the  tympanic  cavity  a  honeycombed  appearance.  In  the  tympanic 
cavity  this  mucous  membrane  is  pale,  thin,  slightly  vascular,  and  cov- 
ered for  the  most  part  with  columnar  ciliated  epithelium,  but  over  the 
pyramidal  eminence,  ossicles  and  membrana  tympani,  it  possesses  a 
flattened,  non-ciliated  epithelium.  In  the  tympanic  antrum  and  mastoid 
cells  the  epithelium  is  also  non-ciliated. 

In  the  Eustachian  tube  the  epithelium  of  the  mucous  membrane 
is  columnar  and  ciliated.  In  the  osseous  portion  of  the  tube  the  mucous 
membrane  is  thin,  but  in  the  cartilaginous  portion  it  is  veiy  thick,  highly 
vascular  and  provided  with  numerous  mucous  glands.  These  anatom- 
ical factoids  are  important  to  remember  in  the  treatment  of  tubal  ca- 
tarrh, tubal  occlusion  and  middle  ear  conditions. 

Lymphatic  Drainage.  The  majority  of  the  lymphatics  of  the 
ear  follow  along  the  Eustachian  tube  and  empty  into  the  retropharyn- 
geal glands.  They  are  drained  by  sweeping  out  the  fossa  of  Rosen- 
muUer.  Others  reach  the  postauricular  glands  over  the  mastoid  pro- 
cess, where  they  can  be  drained  directly.  Both  empty  eventually  into 
the  Superior  Deep  Cervical  Glands  which  must  be  thoroughly  drained 
in  any  middle  ear  condition. 

Lymphatic  Drainage  of  Inner  Ear.  I  have  not  found  any  lym- 
phatic drainage  described  from  the  inner  ear  to  the  cervical  lymphatic 
glands,  but  it  is  likely  that  some  lymphatic  drainage  passes  from  the 
inner  ear  by  way  of  lymph  vessels  accompanying  the  stylomastoid  vein. 
The  perilymph  is  in  communication  with  the  subarachnoid  space  and, 
no  doubt,  drainage  is  dependent  upon  the  difference  in  pressure  between 
the  fluid  in  the  subarachnoid  space,  and  the  fluid  in  the  labyrinth. 

Our  problem  of  relieving  ear  symptoms  due  to  nerve  involvement 
resolves  itself  into  one  of  establishing  free  drainage  from  the  cranial 
cavity.  This  is  best  facilitated  by  thorough  osteopathic  treatment, 
with  special  attention  to  upper  cervical  and  mandibular  lesions,  restor- 
ing free  motion  to  all  vertebrae  and  dilating  abdominal  vessels.  The 
internal  jugular  vein  must  be  relieved  of  back  pressure,  and  no  obstruc- 
tion permitted  to  retard  the  escape  of  cerebrospinal  fluid  into  the  lymph 
spaces  of  the  cranial  and  spinal  nerve  sheaths.  Also,  all  the  emissary 
veins  and  the  anastomosing  veins  must  be  carefully  treated,  such  as 
the  anastomoses  of  the  ophthalmic  with  the  facial,  in  order  that  the 
freest  possible  escape  may  be  afforded  for  the  blood  and  cerebrospinal 
fluid  from  the  cranial  cavity.  Note  particularly  the  vein  connecting 
the  lateral  sinus  with  the  posterior  auricular  or  with  an  occipital  vein. 
Blisters  or  leeches  have  been  applied  here  to  facilitate  cerebral  drainage. 


In  Health  and  Disease  257 

Note  also  the  connection  between  the  cranial  veins  and  the  lateral  sinus 
via  the  diploic  veins.  Note  also  that  the  veins  within  the  cavities  of 
the  nose  and  middle  ear  communicate  with  those  of  the  meninges. 

Acute  Otitis  Media 

Acute  otitis  media  is  divided  clinically  into  Acute  Catarrhal  or 
Non -Suppurative  Otitis  Media,  and  Acute  Suppurative  Otitis  Media. 
Inflammation  of  the  middle  ear  usually  begins  by  extension  from  the 
nasopharynx  via  the  Eustachian  tube,  but  it  may  occur  directly  from 
the  blood  stream.  The  exudate  is  simply  excessive  mucus  or  it  may 
be  purulent.  The  membrana  tympani  has  a  tendency  to  rupture  at 
the  point  of  greatest  bulging,  and  should  be  incised  before  rupture  oc- 
curs. The  simple  catarrhal  secretion  rarely  ruptures  the  membrana 
tympani.  All  cases  begin  with  chills,  fever,  vomiting  and  prostration. 
Most  cases  terminate  in  resolution,  but  some  go  on  to  the  purulent  stage. 
Thorough  osteopathic  drainage  of  the  Eustachian  tube,  and  the  lym- 
phatics, together  with  correction  of  mandibular,  occipital,  cervical, 
and  dorsal  lesions,  usually  control  the  case  if  seen  early.  Opening  the 
mouth  against  resistance  should  be  done  by  the  patients  at  intervals. 
Scarlet  fever  and  measles  very  often  sttack  the  mucous  membrane  of 
the  middle  ear.     In  fact,  every  case  of  exanthematous  disease  or 

OTHER  acute  INFECTION  SHOULD  SUGGEST  CAREFUL  EXAMINATION  OF 
THE  MEMBRANA  TYMPANI  AT  EACH  VISIT,  TO  FORESTALL  TROUBLE.      Much 

of  the  chronic  ear  disease  and  deafness  of  middle  life  is  due  to  neglect 
of  this  precaution. 

Treatment  of  mastoiditis  is  the  same  as  for  middle  ear  with  the 
added  caution  to  be  on  guard  for  indications  that  a  mastoid  operation 
is  needed.  I  have  had  two  severe  cases  of  mastoiditis  where  the  patient 
appeared  in  imminent  danger  of  death  clear  up  by  persistent  osteopathic 
treatment  designed  to  improve  drainage  as  explained. 

In  THESE  CASES,  REMEMBER  THAT  YOU  HAVE  AT  YOUR  DISPOSAL 
THERAPEUTIC  MEANS  THAT  ARE  INFINITELY  MORE  EFFECTIVE  THAN  ANY 
MEDICINAL    MEASURES    AVAILABLE    TO    THE    ALLOPATHIC    AURIST.      If    the 

stage  is  reached  where  mastoid  operation  is  needed  have  it  done  by  the 
most  competent  ear  surgeon  or  brain  surgeon  available,  but  keep  right 
ON  TREATING  THE  PATIENT,  bccausc  the  Osteopathic  treatment  is  fully 
as  important  as  the  operation.  The  operation  only  helps  drain  one 
part.  Remember,  pure  blood  and  plenty  of  it  is  needed  in  the  mastoid, 
middle  ear  and  inner  ear,  and  the  way  to  get  it  there  is  to  establish  free 
drainage  as  explained.  Know  this  part  of  the  work  in  detail  so  that 
you  can  use  it  when  the  time  comes. 


258  Lymphatics 

The  Nose  and  Sinuses  In  Eye  Conditions 

Each  orbit  is  bounded  medially  by  the  frontal,  ethmoidal  and  sphe- 
noidal sinuses  and  below  by  the  maxillary  sinus,  and  separated  from 
these  sinuses  by  only  a  very  thin  plate  of  bone  with  only  a  thin  mucous 
membrane  within  the  sinus.  Thus,  a  closed  empyema  of  any  sinus  may 
be  fraught  with  serious  danger  to  the  orbital  structures.  And  this  is 
further  accentuated  by  blood  and  nerve  supply  being  distributed  from 
practically  the  same  arteries  and  nerve  trunks.  Correction  of  nasal 
and  sinus  conditions  results  in  marked  improvement  in  vision,  which, 
with  supportive  treatment  in  the  upper  dorsal  and  cervical  regions,  is 
permanent. 

A  similar  thin  plate  of  bone  is  all  that  separates  the  sphenoidal, 
ethmoidal  and  frontal  sinuses  from  the  cranial  cavity.  The  cribriform 
plate  of  the  ethmoid  upon  which  rests  the  olfactory  bulb,  is  extremely 
thin  and  perforated  by  numerous,  foramina  for  passage  of  the  olfactory 
nerves,  and  through  these,  infection  is  frequently  carried  from  the  nasal 
cavities  to  the  cerebral  meninges  as  the  nasal  mucosa  is  continuous  with 
the  dura  mater  at  the  foramina.  Swelling  of  the  middle  turbinate  can 
close  the  olfactory  fissure  in  such  a  way  as  to  prevent  ventilation  and 
drainage,  making  it  a  fertile  culture  medium  for  any  pathogenic  micro- 
organisms that  may  lodge  there.  In  this  way  the  optic  nerve  may  be 
affected  within  the  cranial  cavity. 

The  cornea  has  no  trace  of  blood  vessels  except  at  its  extreme  mar- 
gin. A  fine  network  of  lymphatic  spaces  serves  to  nourish  it.  When 
inflamed  it  becomes  opaque,  and  the  blood  vessels,  which  encroach  on 
it  give  a  *' salmon  "  tinge  to  it.  In  pannus,  the  continued  irritation  causes 
blood  vessels  to  pass  over  the  cornea  just  beneath  the  epithelial  cover- 
ing, but  the  cornea  proper  remains  bloodless. 

Blood  to  all  eye  structures  is  almost  entirely  from  branches  of  the 
ophthalmic  artery  which  arises  from  the  internal  carotid  artery,  just 
as  that  vessel  is  emerging  from  the  cavernous  sinus.  In  the  orbit  this 
artery  is  in  relation  with  the  lower  border  of  the  obliquus  superior, 
rectus  superior  and  levator  palpebrae.  Some  of  its  branches  go  to 
the  nose  and  accessory  sinuses.  Any  irritation  in  the  nose  and  sinuses 
to  visceral  afferent  nerves  is  therefore  reflected  in  dilatation  of  the  oph- 
thalmic arterj'  and  its  branches.  Lymphatic  drainage  of  the  nose  and 
sinuses  is  largely  through  the  retropharyngeal  glands.  Therefore,  the 
first  thing  to  do,  to  normalize  the  blood  supply  to  the  eye,  is  to  thor- 
oughly restore  a  normal  healthy  condition  to  the  nose,  sinuses,  pharynx 
and  neck,  as  well  as  to  correct  any  upper  dorsal  or  cervical  lesions  that 
might  affect  the  sympathetic  nerves  in  the  grey  lateral  horn  or  in  the 
suix'rior  or  inferior  cervical  sympathetic  gangUa. 


In  Health  and  Disease  259 

Manipulation  of  the  Eyeball  and  Ad{acent  Structures 

Venous  drainage  of  the  eye  is  three-fold:  into  the  cavernous  sinus, 
pterj^goid  plexus,  and  anterior  facial  vein. 

The  lymphatic  vessels  of  the  eyelids  and  conjunctiva  empty  into 
the  facial  glands,  thence  into  the  parotid  and  submaxillary  glands,  which, 
in  turn,  empty  into  the  upper  deep  cervical  lymphatic  glands.  It  is 
also  to  be  borne  in  mind  that  the  Ij^mph  spaces  around  the  eyeball  and 
within  the  fascia  bulbi  communicate  with  the  subdural  and  subarach- 
noid spaces  in  the  brain,  and  that  any  disturbance  of  the  drainage  of 
the  cerebrospinal  fluid  will  affect  this  drainage,  notably  brain  tumor  or 
meningitis.  Gentle  manipulation  of  the  various  glands  will  stimulate 
their  activity. 

Conjunctivitis  is  materially  helped  by  gently  stroking  the  lids  along 
the  orbital  margins  toward  the  inner  canthus,  as  the  conjunctival  arteries, 
veins  and  lymphatics  are  all  stimulated  in  this  way. 

Granulations  are  crushed  between  the  index  finger  and  thumb,  the 
finger  being  aseptically  clean  and  inserted  beneath  the  lid,  or  with  the 
lid  everted.  Dr.  A.  T.  Still  held  that  many  eye  conditions  were  due  to 
hypertonicity  of  the  orbicularis  muscle,  which  he  relieved  by  stretching 
the  eyelid  by  inserting  his  finger  beneath  the  lid  and  gently  pulling. 
The  lids  may  also  be  pulled  from  side  to  side. 

The  drainage  of  the  eyeball  and  orbit  can  be  improved  by  pressing 
the  outer  side  of  the  tip  of  the  little  finger  deep  into  the  orbit  and  push- 
ing the  eyeball  as  far  as  possible  in  every  direction.  Dr.  T.  J.  Ruddy, 
of  Los  Angeles, has  devised  the  "Ruddy  Eye  Finger"  to  facilitate  eye 
manipulation. 

Treatment  of  conjunctivitis  is  mainly  osteopathic.  Drain  and 
manipulate  as  described  above.  The  conjunctiva  cannot  stand  strong 
antiseptics.  Even  25%  argyrol  when  used  for  several  months  perma- 
nently discolors  the  sclera  brown,  known  as  argyria.  Alkalol  50%,  nor- 
mal saline,  saturated  solution  of  boric  acid,  pure  water,  are  usually  the 
best  eye-washes,  to  be  applied  by  winking  the  eye  in  an  eye  cup.  They 
should  be  ice-cold  if  given  at  the  first  stage  of  inflammation,  otherwise 
as  hot  as  can  be  borne.  Cold  compresses  wrung  out  in  ice-wat€r,  or 
just  off  the  ice,  may  be  also  applied  at  the  beginning  of  conjunctivitis, 
but  ice  should  not  be  applied.  Later  in  the  conjunctivitis,  hot  com- 
presses should  be  applied.  A  weak  solution  of  zinc  sulphate,  (5  to  2%) 
is  veiy  effective  in  destroying  the  Morax-Axenfeld  bacillus  which  is 
present  in  angular  conjunctivitis  and  causes  a  tenacious  grey  discharge 
that  glues  the  lid. 


260  Lymphatics 

Always  wear  protective  glasses  whenever  examining  an  eye  that 
is  glued  shut,  as  the  pent-up  secretions  may  squirt  into  your  own  eye 
when  you  succeed  in  getting  the  lids  separated  a  little. 

Considering  the  various  causes  given  by  medical  authors  for  cata- 
ract, glaucoma  and  other  eye  diseases  which  do  not  yield  to  medicinal 
therapy,  it  is  easy  to  see  how  osteopathic  lesions  affecting  the  blood 
supply,  nerve  supply,  venous  drainage  and  lymphatic  drainage  are  re- 
sponsible for  most  of  these  cases.  Many  of  these  cases  can  be  cured 
by  osteopathy,  plus  hygiene.  It  is  the  duty  of  everj'  osteopath  to  know 
enough  about  them  to  give  the  patient  the  right  treatment  or  at  least 
to  refer  him  to  the  right  specialist. 

Dr.  J.  D.  Edwards  of  St.  Louis,  Mo.,  in  the  May,  1920,  A.  O.  A. 
Journal,  described  his  original  technique  under  the  title  of  "Finger  Sur- 
gery of  the  Orbital  Cavity  in  the  Treatment  of  Glaucoma. "  He  states 
that  "the  results  of  this  local  manipulation  in  glaucoma  in  many  in- 
stances were  very  gratifying.  Muscae  Volitantes,  synechia  of  the  iris, 
staphyloma,  asthenopia,  strabismus,  incipient  cataracts,  retinal  de- 
tachment,  choroiditis,  iritis,  simple  retinitis,  refractive  errors,  uveitis, 
dacrocystitis,  epiphora,  blepharitis,  conjunctivitis,  optic  nerve  atrophy, 
have  responded  to  this  technique,  and  with  the  exception  of  the  specific 
and  malignant  diseases,  which  should  be  carefully  differentiated,  almost 
every  morbid  condition  of  the  orbital  cavity  can  be  benefited  if  not  en- 
tirely cured."  Dr.  Curtis  H.  Muncie,  of  New  York,  in  the  October, 
1921  A.  O,  A.  Journal  described  additional  finger  surgery  technique  to 
correct  errors  of  refraction  by  controlling  drainage. 

As  a  matter  of  fact,  this  technique  secures  far  better  results  than 
any  of  the  ordinary  methods,  such  as  eye-drops,  eye-glasses,  rest  in 
dark  rooms,  etc.  The  discovery  of  Dr.  Bates  of  New  York  is  reallj^  oste- 
opathic. Let's  make  the  most  of  it.  His  medical  confreres  are  as  slow 
to  take  it  up  as  they  were  to  take  up  osteopathy.  And  osteopaths  for 
forty  years  have  been  taking  off  peoples'  glasses  by  simply  noiTnalizing 
the  spine,  whereupon  the  underlying  cause  of  the  strain  was  removed 
and  the  errors  of  refraction  cleared  up. 

The  circulation  to  the  brain  is  interfered  with  by  any  lesion,  bony, 
ligamentous,  muscular,  etc.,  which  narrows  the  lumen  of  the  spinal 
canal  at  the  foramen  magnum  or  further  down.  Such  a  lesion  reduces 
the  normal  interchange  of  cerebrospinal  fluid  between  the  ventricles 
and  the  spinal  canal  at  each  heart-beat.  Owing  to  the  rigidity  of  the 
cranium,  cerebrospinal  fluid  must  leave  the  ventricles  at  systole  as  the 
arteries  within  the  cranium  dilate.  If  it  does  not,  cerebral  ischaemia, 
increased  intracranial  pressure,  or  congestion  will   occur.     This   tends 


In  Health  and  Disease    ,  261 

to  irritate  the  vagus  and  autonomic  fibres  to  hyperactivity,  and  to  set 
up  an  irritabihty  or  instabiHty  reflexly  from  the  cerebral  cortex  in  every 
cell,  tissue  and  organ  in  the  body.  Occipital  or  cervical  lesions  causing 
this  condition  must  be  corrected.  Cerebral  ischaemia  may  also  result 
from  insufficient  heart  action  due  to  vasoconstrictor  paralysis  and  lack 
of  accelerator  and  augmentor  impulses,  caused  by  upper  dorsal  lesions, 
or  to  inhibition  of  sympathetic  impulses  over  the  vertebral  and  internal 
carotid  arteries.  The  headaches,  depression,  and  emotional  insta- 
bility of  hay  feverites  are  all  markedly  improved  after  correction  of 
lesions  in  these  regions. 


GEO.  M.  LAUGHLIN,  M.S.,  D.O. 

KiRKSVILLE,  Mo. 


CHAPTER  FIFTEEN 

THE  RELATION  OF  THE  LYMPHATICS  TO 
INFECTIONS  AND  TO  MALIGNANCY 

Geo.  M.  Laughlin,  M.  S.,  D.  O.,  Kirksville,  Mo. 

The  purpose  of  this  chapter  is  to  show  the  relation  between  lymph 
glands  and  infections,  and  also  the  relation  between  lymph  glands  and 
malignant  diseases  in  various  parts  of  the  body.  A  focal  infection  may 
spread  throughout  the  body  along  the  lymph  channels  or  through  the 
blood  stream.  Where  the  infection  travels  along  the  lymph  channels, 
we  usually  find  the  lymph  glands  involved,  which  involvement  is  char- 
acterized by  an  enlargement  of  the  glands.  This  is  probably  a  part  of 
our  defensive  mechanism  against  the  spread  of  an  infection.  The  same 
thing  also  applies  in  cases  of  malignant  disease.  The  cancer  cells  trav- 
eling through  the  lymph  spaces  attack  the  lymph  glands  in  close  prox- 
imity to  the  seat  of  the  disease  and  this  involvement  is  characterized  by 
an  enlargement  of  the  glands.  Cancer  cells  are  also  carried  through  the 
blood  stream.  I  herewith  report  a  number  of  cases  that  have  recently 
come  under  our  observation  wherein  the  involvement  of  the  lymph  glands 
in  the  neighborhood  of  an  infection  or  in  some  cases  at  a  considerable 
distance  from  the  primary  infection  was  manifested  by  an  enlargement 
of  the  glands  and  in  some  cases  by  their  destruction,  but  in  all  cases  of 
infection  herein  reported  the  infection  was  limited  to  the  original  focus  and 
the  neighboring  lymph  glands  which,  no  doubt,  performed  the  function 
of  preventing  a  further  spread  of  the  infection  even  though  the  lymph 
glands  were  in  some  instances  destroyed.  In  all  cases  of  malignant  dis- 
ease where  the  lymph  nodules  were  involved  secondarily,  there  was  no 
improvement  except  where  the  malignant  focus  was  removed  altogether 
with  all  lymph  glands  involved. 

Case  1.  A  lad  eight  j^ears  old  was  brought  to  the  hospital  with 
a  mild  infection  involving  the  right  elbow.  There  was  limited  motion 
but  not  any  great  amount  of  pain  or  swelling.  An  X-ray  picture  did 
not  show  any  involvement  of  the  bone.  A  careful  examination  re- 
vealed a  very  active  infection  of  both  tonsils.  These  were  enucleated 
and  the  adenoids  removed  cleanly.  The  infection  in  the  arm  became 
quiescent  after  a  week  or  ten  days.  In  this  case  undoubtedly  the  in- 
fection in  the  arm  was  secondary  to  the  infection  in  the  throat,  and  the 
infection  reached  the  arm  through  the  blood  stream.  The  arm  was 
given  no  treatment  of  a  manipulative  character  except  a  very  gentle 

—263— 


264 


Lymphatics 


Plate  LXX.-Case  1. 


Relation  to  Infections  and  to  Malignancy  266 

massage.  Hot  applications,  however,  were  applied  for  a  few  days.  The 
special  feature  of  this  case,  however,  was  an  involvement  of  the  lymph 
glands  in  the  back  of  the  head,  four  or  five  of  the  mastoid  and  occipital 
glands  were  enlarged  to  the  size  of  a  large  hazelnut.  They  were  not 
especially  tender,  however,  on  pressure,  and  were  quite  hard.  There 
did  not  seem  to  be  any  relation  between  the  enlargement  of  these  glands 
and  the  infection  in  the  throat,  but  there  were  several  patches  on  the 
top  of  his  head,  some  of  them  almost  as  large  as  a  silver  dollar,  where 
there  was  an  active  infection  with  a  sticky  excretion  which  caused  the 
hair  to  mat.  These  sores  on  his  head  were  healed  after  about  two  weeks' 
treatment,  which  consisted  of  clipping  the  hair  close  to  the  scalp  and 
cleansing  the  sores  with  soap  and  then  putting  on  zinc  oxide  ointment. 
Undoubtedly  this  infection  in  his  scalp  was  responsible  for  the  enlarge- 
ment of  the  glands  in  the  occipital  and  mastoid  regions,  as  the  lymph 
vessels  range  from  the  top  of  the  head  downward.  Following  the  heal- 
ing of  the  sores  on  the  boy's  head,  the  enlarged  lymph  glands  gradually 
receded.  The  accompanying  illustration  shows  the  lymph  glands  in- 
volved and  the  source  of  the  infection.  In  cases  of  this  kind,  the  en- 
larged Ij^mph  glands  require  no  direct  special  treatment  where  the 
glands  have  not  broken  down.  Where  the  primary  focal  infection  is 
cleaned  up,  the  glands  will  recede  to  normal  size.  Where  the  glands 
have  suppurated,  drainage  by  incision  is  necessary. 

Case  2.  The  patient,  a  girl  about  15  years  of  age,  had  a  swelling 
on  the  right  side  of  her  neck  nearly  as  large  as  a  hen's  egg.  The  lump 
was  immediately  in  front  of  the  sternomastoid  muscle  and  the  top  of 
it  was  about  on  a  level  with  the  angle  of  the  jaw.  This  swelling  persisted 
for  a  number  of  months.  It  appeared  to  be  a  single  lymph  gland  greatly 
enlarged,  although  there  may  have  been  several  glands  which  had  co- 
alesced. There  seemed  to  be  no  tendency  for  the  enlargement  to  recede. 
The  patient  gave  a  history  of  having  had  a  considerable  amount  of  throat 
infection,  although  at  the  time  the  case  came  under  our  observation  the 
throat  seemed  to  be  fairly  clean.  The  question  arose  as  to  the  nature 
of  the  swelling  and  as  to  the  best  treatment  to  apply  to  reduce  it.  As* 
the  parents  of  the  child  were  adverse  to  operation,  an  attempt  was  made 
to  reduce  the  swelling  by  treating  the  neck  osteopathically,  and  also 
by  the  use  of  applications  such  as  antiphlogistine,  hot  water,  etc.  This 
treatment,  however,  was  carried  on  without  success.  Next  the  swelling 
was  incised  and  a  considerable  amount  of  pus  evacuated.  A  drain  was 
introduced  and  this  treatment  for  the  time  being  reduced  the  swelling 
to  a  considerable  extent.  After  a  time  the  drain  was  discarded  and  the 
incision  healed,  but  in  a  short  time  the  gland  swelled  up  again  as  large 


2{)Cy 


Lymphatics 


^^tf-'PTV. 

j®*  ,> 

\ 

Mm 

's 

^g' 

Plate  LXXI.— Case  2. 


Relation  to  Infections  and  to  Malignancy  267 

as  it  was  before  treatment.  We  next  opened  the  abscess  and  after  drain- 
ing out  a  considerable  quantity  of  pus,  injected  the  cavity  with  bismuth 
paste.  This  treatment  after  being  tried  for  a  couple  of  months  proved 
to  be  unsuccessful.  Finally,  under  an  anesthetic,  the  swelling  was 
opened  freely  and  the  wall  of  the  abscess  dissected  away.  The  wound 
was  drained  for  a  few  days  only  and  healed  readily  without  any  further 
recurrence  of  the  trouble.  I  do  not  believe  this  infection  was  tubercu- 
lar in  character  as  the  infection  was  limited  to  one  area.  The  glands 
in  this  case  were  secondarily  involved  from  an  infection  in  the  throat 
of  a  pyogenic  character. 

Tuberculosis  of  the  lymph  glands  is  characterized  usually  by  the 
fact  that  a  considerable  number  are  involved,  and  in  the  beginning  the 
glands  are  very  hard  and  do  not  enlarge  rapidly.  I  might  add  in  this 
connection  that  as  a  rule  tubercular  glands,  if  the  proper  hygienic  treat- 
ment is  carried  on,  will  recede  without  surgical  interference.  As  a  rule, 
enlarged  lymph  glands  in  the  neck  in  front  of  the  sternomastoid  muscle 
and  below  the  jaw,  where  the  condition  is  due  to  acute  or  chronic  ton- 
sillitis, will  recede  to  a  normal  state  after  the  condition  in  the  throat  is 
cured,  whether  by  operation,  as  the  removal  of  the  tonsils,  or  by  other 
means.  We  do  not  consider  it  wise  as  a  rule  to  manipulate  an  enlarged 
lymph  gland.  The  treatment  should  be  directed  to  the  cause  of  the 
trouble  and  the  gland  itself  requires  no  treatment  of  any  character  ex- 
cept perhaps  local  applications,  unless  the  enlargement  is  considerable 
and  persists  for  some  time  or  unless  the  gland  suppurates  and  breaks 
down.  In  the  case  of  suppuration,  usually  drainage  is  all  that  is  re- 
quired.    Occasionally  excision  as  in  the  present  case  will  be  necessary. 

Case  3.  A  lad  10  years  of  age  injured  his  leg  about  six  inches  above 
the  ankle  by  striking  it  against  the  tongue  of  a  cultivator.  The  injury 
at  the  time  was  considered  trivial,  although  it  was  somewhat  painful  for 
a  few  minutes.  No  attention  was  paid  to  the  bruise  for  a  week  or  ten 
days,  when  the  lad  developed  a  considerable  swelling  at  the  place  of  in- 
jury and  also  complained  of  pain.  An  attempt  was  made  at  treatment 
by  home  remedies  and  bandaging,  but  there  was  no  improvement,  and 
after  about  a  month  the  boy  was  brought  to  the  hospital  at  which  time 
he  was  running  a  little  temperature  and  the  pain  in  the  leg,  although 
not  severe,  was  enough  to  cause  him  considerable  annoyance.  There 
was  a  swelling  at  the  site  of  the  injury  and  the  skin  was  considerably  dis- 
colored for  an  area  of  several  inches.  Although  the  skin  was  not  broken 
at  the  time  of  injury,  there  was  evidently  an  infection  here  which  was 
characterized  by  a  soft  swelling,  discoloration  of  the  skin  and  tempera- 
ture.    The  infection  was  evidently  carried  to  the  involved  tissues  through 


268 


Lymphatics 


Plate  LXXIL— Case  3. 


Relation  to  Infections  and  to  Malignancy  269 

the  blood  stream,  gaining  entrance  to  the  body  probably  through  the 
throat,  although  there  was  no  history  of  any  special  throat  trouble.  The 
infection  proved  to  be  quite  superficial,  lying  between  the  fat  and  down 
upon  the  fascia  overlying  the  muscles  just  a  little  outside  of  the  tibia. 
This  was  incised  for  a  couple  of  inches  and  a  considerable  quantity  of 
pus  escaped.  The  cavity  was  curretted  and  drained.  It  healed  in 
about  two  weeks. 

The  special  feature  of  this  case,  and  for  which  it  is  principally  pre- 
sented, was  the  involvement  of  the  inguinal  lymph  glands.  These  glands 
were  enlarged,  some  of  them  to  half  the  size  of  a  hen's  egg.  One  gland 
had  suppurated  and  required  incision  for  drainage.  Following  the 
drainage  of  the  abscess  in  the  leg  and  the  incision  for  drainage  of  the 
lymph  gland  that  had  suppurated,  the  balance  of  the  glands  receded  to 
normal  size  in  about  ten  days.  The  only  treatment  was  rest  in  bed. 
Undoubtedly  infection  from  the  leg  in  this  case  followed  along  the  lymph 
channels  until  the  lymph  glands  in  the  groin  were  reached,  and  here  the 
infection  was  limited.  The  accompanying  illustration  shows  the  route 
the  infection  travelled  to  reach  the  lymph  glands  in  the  groin.  It  is 
not  uncommon  for  an  infection  in  the  foot,  particularly  an  infection 
from  an  ingrown  toe-nail,  to  cause  an  involvement  of  the  lymph  glands 
in  the  groin. 

Case  4.  I  wish  next  to  report  a  case  of  involvement  of  the  deep 
lymph  glands  along  the  external  iliac  vessels.  The  case  was  unusual 
for  the  reason  that  the  glands  were  so  large  that  they  had  been  mistaken 
for  a  fibroid  tumor  of  the  uterus.  This  patient,  a  young  woman  about 
30  j^ears  of  age,  had  given  birth  to  a  child  about  three  months  before 
she  came  under  our  observation.  There  was  a  history  of  unsatisfactory 
convalescence  following  delivery.  The  patient  had  never  been  well 
enough  to  nurse  her  baby.  On  examining  the  case  after  she  was  brought 
into  the  hospital,  we  found  a  large  solid  growth  extending  a  little  past 
the  mid-line  of  the  abdomen  on  the  right  and  up  to  within  two  inches  of 
the  mnbilicus,  and  then  extending  clear  over  to  the  left  side  forming  an 
immovable  mass.  The  superficial  lymph  glands  in  the  inguinal  region 
were  also  enlarged.  There  was  a  slight  discharge  of  pus  from  the  uterus; 
she  was  running  an  irregular  temperature.  An  incision  was  made  over 
the  mass  but  without  opening  the  peritoneal  cavity,  as  the  mass  below 
was  attached  to  the  abdominal  wall.  A  finger  was  inserted  down  into 
the  mass  and  a  large  quantity  of  pus  escaped.  A  drainage  tube  was  then 
introduced  and  left  in  the  wound  until  drainage  ceased  and  the  mass  re- 
duced. This  required  about  three  weeks.  The  patient  made  a  very 
satisfactory  recovery  although  the  wound  was  slow  in  healing,  a  little 


270 


Lymphatics 


Plate  LXXIIL— Case  4. 


Relation  to  Infections  and  to  Malignancy  271 

discharge  occurring  for  four  or  five  weeks.  The  entire  mass,  however, 
entirely  disappeared  after  six  weeks. 

The  infection  in  this  case  undoubtedly  came  from  the  uterus  and 
occurred  in  connection  with  delivery,  due  probably  to  the  introduction 
of  unclean  hands  or  instruments  into  the  vagina  or  uterus.  When  I  first 
saw  the  case  I  was  somewhat  in  doubt  as  to  whether  or  not  there  might 
be  a  malignant  condition.  When  the  mass  was  incised  and  pus  escaped, 
I  was  then  satisfied  that  we  had  only  an  infection  to  deal  with.  The  sub- 
sequent history  of  the  case  demonstrated  this  to  be  true.  The  accom- 
panying illustration  shows  the  lymph  drainage  from  uterus  and  the 
lymph  glands  along  the  iliac  vessels.  The  reason  cancer  of  the  uterus 
is  so  frequently  ultimately  a  fatal  disease  is  on  account  of  the  involve- 
ment of  these  lymph  glands,  which  cannot  always  be  entirely  removed, 
even  though  wide  dissection  of  the  parametrium  is  made  at  the  time  of 
operation  for  the  removal  of  the  uterus.  Where  malignant  lymph  glands 
remain  after  the  removal  of  the  uterus,  the  disease  recurs. 

Case  5,  is  that  of  a  young  man  about  twenty,  an  ex-soldier.  He  was 
brought  to  the  hospital  for  treatment  for  a  disabled  hip.  He  was  un- 
able to  walk  due  to  the  disability  and  it  was  thought  that  perhaps  the 
condition  was  one  which  might  be  relieved  by  some  sort  of  treatment. 
The  history  was  not  clear  except  that  the  hip  had  grown  progressively 
worse  following  a  slight  injury.  At  the  time  we  saw  the  case  the  hip 
was  enlarged  from  the  crest  of  the  ilium  down  to  six  or  eight  inches  be- 
low the  great  trochanter.  There  was  an  especially  large  swelling  in  the 
gluteal  region.  Both  the  deep  and  superficial  lymph  glands  in  the  groin 
and  abdomen  on  the  same  side  were  extensively  enlarged.  There  was 
a  firm  mass  here  which  extended  well  into  the  abdomen.  The  young 
man  had  lost  considerable  weight,  bilt  so  long  as  he  was  quiet  in  bed 
there  was  little  or  no  pain.  There  was  no  temperature.  An  incision 
was  made  over  the  large  mass  in  the  gluteal  region  and  a  large  quantity 
of  broken  down,  flesh-like  material  removed.  The  object  of  the  opera- 
tion was  to  determine  the  character  of  the  growth.  No  pus  was  present. 
An  examination  of  the  tissue  proved  it  to  be  sarcoma  which  probably 
had  originated  in  the  region  of  the  hip,  either  in  the  soft  tissues  or  from 
the  bone.  The  involvement  of  the  lymph  glands,  of  course,  was  entirely 
secondary  in  this  particular  case.  The  wound  was  sutured  and  healed 
without  any  trouble.  The  disease,  however,  progressed  steadily  and 
the  young  man  was  sent  home.  He  died  about  two  or  three  months 
later. 

This  case  serves  to  illustrate  the  involvement  of  lymph  glands  in 
malignant  disease.     The  glands  involved  are  those  adjacent  t-o  the  seat 


272 


Lymphatics 


Plate  LXXIV— Case  5. 


Relation  to  Infections  and  to  Malignancy  273 

of  disease.  The  object  of  the  incision  was  to  determine  whether  the 
disease  in  the  hip  was  mahgnant  or  due  to  infection.  It  was  quite  evi- 
dent, however,  even  before  operation,  that  the  condition  was  mahg- 
nant, but  as  there  was  no  risk  in  making  the  incision  it  was  done  with 
the  hope  that  the  condition  might  prove  to  be  an  infection,  in  which 
case  an  improvement  could  have  been  expected  from  treatment. 

Case  6.  This  case  is  given  for  the  purpose  of  illustrating  the  in- 
volvement  of  axillary  lymph  glands.  The  patient,  Mrs.  M.,  55  years 
of  age,  was  examined  only  recently  for  an  enlargement  in  her  breast. 
It  was  a  single  lump  about  the  size  of  a  walnut  just  a  little  to  the  out- 
side of  the  nipple.  The  lump  had  given  her  considerable  pain,  and 
there  had  been  a  discharge  of  blood  and  serum  through  the  nipple  for 
a  couple  of  months.  The  lump,  however,  was  not  attached  to  the  skin 
nor  to  the  muscle  beneath.  Upon  examining  the  axilla,  we  found  a 
few  lymph  glands  slightly  enlarged.  The  patient  was  considerably 
distressed  about  the  condition  and  thought  it  might  be  malignant.  I 
was  inclined  to  believe  that  it  was  non-malignant,  but  recommended 
operation.  The  breast  was  removed  and  the  axilla  cleaned  out,  strip- 
ping out  the  fat  and  the  lymph  glands  along  the  axillary  vessels.  The 
tumor  was  cut  open  and  proved  to  be  a  broken  down  cyst.  The  cyst 
had  become  infected  and  the  lymph  glands  were  enlarged  secondarily  to 
the  infection.  There  was  no  evidence  of  malignancy,  although  condi- 
tions  of  this  kind  if  allowed  to  run  often  become  malignant,  and  for 
that  reason  the  operation  was  advised. 

In  this  case  it  was  not  found  necessary  to  remove  the  pectoral  mus- 
cles. The  patient,  of  course,  has  experienced  a  great  deal  of  relief  both 
in  mind  and  body  following  the  operation  and  may,  of  course,  expect 
permanent  relief  without  fear  of  recurrence. 

I  wish  in  this  connection  to  report  a  case  of  carcinoma  of  the  breast 
in  a  woman  of  about  60  years  of  age  where  the  condition  had  existed  for 
over  a  year.  The  skin  for  about  an  inch  about  the  nipples  had  broken 
down  and  there  was  a  large  lump  as  big  as  one's  fist  in  the  middle  of 
the  breast.  The  lymph  glands  in  the  axilla  were  palpable,  some  of  them 
as  large  as  a  small  sized  hickory  nut.  The  lump,  however,  was  mov- 
able.  In  this  case  a  very  wide  incision  was  made  and  the  breast  and 
pectoralis  major  and  minor  muscles  were  removed  down  to  the  ribs. 
The  fat  and  lymph  glands  were  removed  from  the  axilla  for  a  consid- 
erable distance.  Whether  or  not  the  operation  will  eventually  prove 
successful  depends,  of  course,  upon  whether  or  not  all  of  the  lymph  glands 
containing  cancer  cells  were  removed.  There  did  not  appear  to  be 
any  involvement  of  the  tissue  outside  of  the  breast  itself  excepting  the 
skin  about  the  nipple  and  the  lymph  glands.     The  wound  healed  readily 


274 


Lymphatics 


Plate  LXXV.— Case  6. 


Relation  to  Infections  and  to  Malignancy  275 

and  the  patient  regained  good  use  of  the  arm.  The  operation  was  per- 
formed only  a  year  ago  and  to  date  there  has  been  no  recurrence.  We 
are  not  safe,  however,  until  a  number  of  years  have  elapsed  in  saying 
that  the  disease  has  been  entirely  eradicated. 

I  recall  one  case  of  cancer  of  the  lung  which  developed  10  years 
after  the  removal  of  the  breast.  I  recall  another  case  in  which  the 
breast  and  lymph  glands  had  been  removed  and  where  the  disease  re- 
curred several  years  later  in  the  axillary  vessels  and  nerves,  resulting 
in  obstruction  of  the  circulation  to  the  arm  and  intense  pain  due  to  the 
encroachment  of  the  disease  upon  the  nerves. 

In  cancer  of  the  breast  unless  the  operation  is  comparatively  early 
and  the  breast  and  underlying  fascia  and  axillary  lymph  glands  are 
completeh'  removed,  the  disease  is  very  apt  to  recur.  The  most  com- 
mon site  of  recurrence  is  in  the  axillary  tissue,  but  not  infrequently 
metastatic  cancer  appears  in  the  lung,  pleura,  spinal  column  or  brain. 
The  accompanying  illustration  shows  the  lymph  drainage  from  the 
breast  and  the  way  by  which  the  lymph  glands  in  the  axilla  become  in- 
volved at  a  comparatively  early  date  following  the  appearance  of  mal- 
ignancy of  the  breast. 

Case  7.  This  case,  Mrs.  C,  aged  58  years,  came  to  the  hospital 
for  examination  giving  a  history  of  having  had  stomach  trouble  for  about 
a  year.  Her  general  condition  seemed  fairly  good  although  she  had 
lost  some  weight.  There  had  been  more  or  less  distress  for  a  number 
of  months  after  eating  and  she  had  for  some  months  vomited  quite  a 
good  deal,  although  for  several  months  just  preceding  the  time  of  ex- 
amination there  had  been  very  little  vomiting.  A  barium  meal  was 
given  and  the  patient's  stomach  examined  with  the  fluoroscope.  There  was 
quite  an  extensive  filling  defect  along  the  region  of  the  lesser  curvature. 
As  the  patient  was  rather  heavy,  nothing  of  a  very  definite  nature  could 
be  determined  upon  palpation  except  that  the  stomach  was  tender. 
An  examination  of  the  stomach  contents  was  not  made.  The  diagnosis  of 
obstruction  was  made  from  the  fluoroscopic  examination  and  it  was 
thought  that  the  condition  was  either  cancer  or  obstruction  due  to  old 
ulcers.  An  exploratory  operation  was  advised  and  accepted  by  the 
patient.  An  incision  was  made  in  the  mid-line  between  the  ensiform 
and  imibilicus  and  the  stomach  examined.  There  was  an  extensive 
cancer  which  involved  practically  all  of  the  lesser  curvature  and  extend- 
ing well  down  toward  the  great  curvature.  The  stomach  could  not 
]:>e  brought  out  through  the  wound.  The  lymph  glands,  particularly 
along  the  lesser  curvature,  could  be  palpated.  On  account  of  the  ex- 
tensive nature  of  the  disease,  no  attempt  was  made  to  resect  the  stom- 
ach.    There  was  no  evident  involvement  of  the  liver.     The  wound  was 


276 


Lymphatics 


Relation  to  Infections  and  to  Malignancy 


277 


o 


278  Lymphatics 

sewed  up  and'  the  patient  recovered  from  the  operation  and  left  the 
hospital  in  three  weeks. 

This  case  is  reported  to  show  the  futility  of  attempting  to  resect 
the  stomach  except  where  the  operation  is  done  early  and  while  the  dis- 
ease is  still  confined  to  a  small  area,  which,  together  with  the  adjacent 
lymph  glands,  can  be  removed  by  resection.  The  accompanying  illus- 
tration shows  the  blood  supply  to  the  stomach,  its  lymphatics,  and  ad- 
jacent lymph  nodules.  Along  the  lesser  curvature  the  lymphatics  run 
in  a  direction  away  from  the  pylorus  to  terminate  in  the  nodes  along  this 
border  of  the  stomach.  Along  the  greater  curvature,  the  drainage  is 
towards  the  pylorus. 

Case  8.  Mrs.  M.,  age  60,  had  been  under  a  doctor's  care  for  three 
months  previous  to  the  time  she  was  referred  to  me.  The  nature  of 
her  trouble  had  not  been  determined,  although  she  had  lost  considerable 
weight  and  had  suffered  a  great  deal  from  distention  of  the  abdomen, 
vomiting  and  constipation.  Her  condition  became  rapidly  worse  for 
a  week  preceding  the  time  she  was  brought  to  the  hospital.  Upon  ex- 
amination we  found  her  abdomen  distended  and  upon  palpation  found 
a  small  lump  low  in  the  abdomen  on  the  right  side  which  could  be  moved 
about.  The  patient  had  not  be^n  able  to  retain  food  for  almost  a  week. 
There  was  evidence  pf  obstruction  of  the  bowel,  the  nature  of  which  we 
were  unable  to  determine  at  the  time  of  examination.  Operation  was 
recommerided  which  was  performed  as  soon  as  the  patient  could  be 
prepared.  The  abdomen  was  opened  with  a  right  rectus  incision  and 
upon  exploring  we  found  an  obstruction  in  the  small  intestine  which 
proved  to  be  a  growth  inside  of  the  gut  which  almost  completely  ob- 
structed it.  The  lymph  nodes  in  the  mesentery  were  also  involved. 
About  six  inches  of  gut  were  resected  and  a  "V"  shaped  section  of  the 
mesentery  removed  back  of  its  posterior  attachment.  Both  ends  of  the 
bowel  were  closed  by  purse-string  suture  and  a  lateral  anastomosis  per- 
formed.  The  patient  made  a  verj'^  good  recovery  and  has  been  well  up 
to  dat<^,  two  years  following  the  operation.  An  examination  of  the 
tumor  proved  it  to  be  carcinoma.  The  probabilities  are  that  the  pa- 
tient will  have  no  recurrence,  but  we  cannot  positively  state  this  to  be 
true  until  several  j'cars  more  have  elapsed.  This  case  is  presented  for 
the  purpose  of  showing  how  cancer  of  the  colon  or  small  intestine  in- 
volves the  lymph  glands  of  the  mesenter>%  and  an  operation,  unless  it 
is  sufficiently  wide  in  resection  of  the  gut  and  mesentery  to  include  all 
of  the  involved  lymph  glands,  there  is  certain  to  be  early  recurrence  of 
the  disease.  The  accompanying  illustration  shows  the  extent  of  the 
involvement  of  the  lymph  glands  in  this  particular  case  and  the  rather 
wide  resection  necessarj'  for  their  removal. 


Date  Due 

MflV  1 

1 

1<C^A/(V 

^JUL  '6  " 

«44ll< 

\\\H       1 

-iq48 

OCT      5 

1948 

APR 

1952 

"ft!tr 

19*^4 

f\Uu 

9 

S»i   L18BAB''  f  »£H2ll 


A     000  510  526     7 


A    000 


% 


"^ 


^ 


WHTOO 
M6U5a 
1922 

Millard,  Frederick  P 

Applied  anatomy  of  the  lymphatics 


WHTOO 
M6U5a 
1922 

Millerd,  Frederick  P 
I   API lied  anatomy  of  the  lymphatics, 

MEDICAL  SCIENCES  LIBRARY 
UNIVERSITY  OF  CALIFORNIA,  IRVINE 
)  IRVINE,  CALIFORNIA  92664 

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